Archived: Shakespeare Road Medical Practice

We carried out an announced comprehensive inspection of Shakespeare Road Medical Centre between 18 and 27 July 2022. At the time of our inspection this service was registered with us as Shakespeare Road Medical Practice.

During a Care Quality Commission (CQC) monitoring call in April 2022 we identified that there were some areas we needed to obtain further assurances on by way of an onsite inspection. CQC had not carried out an onsite inspection of this service since 2018. We did not rate the provider following the July 2022 inspection because there were some outstanding registration processes which needed to be completed in order for us to be able to rate the service.

In 2018 we inspected the service and rated it as Good overall. In 2020 we also carried out a remote inspection of this service and we did not rate the service.

At the time of inspecting Shakespeare Road Medical Centre, The Practice Surgeries Limited was the provider responsible for the provision of services and the delivery of regulated activities there.

The Care Quality Commission has previously inspected Shakespeare Road Medical Centre in 2018 and in 2020. During those inspections the service was known as The Bermuda Practice Partnership. In 2018 we rated the service Good overall. In 2020 we sought assurances around potential risks to patients by carrying out a focused inspection which was unrated. We took enforcement action against the service by adding conditions to their registration with the CQC in order to drive improvements.

The full reports for previous inspections, including those under its previous providers, can be found by selecting the ‘all reports’ link then searching for Shakespeare Road Medical Practice and The Bermuda Practice Partnership on our website at www.cqc.org.uk on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up on the Direct Monitoring call we carried out in April 2022. This location had not been inspected since December 2020 when it was identified that there were some areas that needed to be reviewed.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included

• Conducting staff interviews using video conferencing facilities.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We found that:

We were not assured the systems and processes in place were operated effectively to enable the registered person, in particular, to assess, monitor and improve the quality and safety of the services provided in the carrying on of regulated activities.

• The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm.
• Responsibilities and roles were unclear and the overall governance arrangements were not always effective, in particular responsibility and oversight on the summarising of patient records, risk assessments, action plans, and improving patient access.
• At the time of the inspection there was a backlog of 2,794 patient records that had not been summarised.
• Patients could not always access care and treatment in a timely way.
• Not all patients were able to access the telephone system in a timely manner.
• We were not assured there was clinical oversight and supervision for staff who were responsible for coding patient records. Staff reported that they had not had sufficient training to undertake this role confidently.
• The practice’s uptake of the national screening programme for cervical and breast cancer screening was below the national target.
• The practice did not have an effective monitoring system in place to assure themselves that blank prescription forms were recorded correctly, and their use was monitored in line with national guidance.
• Feedback from patients about the way staff treated people was not always positive.

We found breaches of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Improve the overall risk assessment process and ensure that ongoing actions are completed and recorded.
• Establish systems and processes for the training of non-clinical staff to a level to enable them to code patient records accurately including oversight and clinical supervision.
• Improve and embed the process relating to prescription stationary.

The provider should:

• Take steps to improve telephone access.
• Take steps to improve arrangements relating to fire safety.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services