Archived: Block Lane Surgery

We carried out an announced inspection at Block Lane Surgery on 5 May 2022. Overall, the practice is rated as requires improvement, with the following key question ratings.

Safe - requires improvement

Effective - good

Caring - good

Responsive - requires improvement

Well-led - requires improvement

The practice had been registered with the Care Quality Commission (CQC) as a partnership in March 2022. Prior to this the practice had been registered under a different registered provider.

Why we carried out this inspection

This inspection was a full comprehensive inspection carried out due to the change in registration.

How we carried out the inspection/review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting interviews using video conferencing
• Sending questionnaires to staff
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• 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 have rated this practice as Requires Improvement overall

We rated the practice requires Improvement for providing safe services:

We found that:

• Alerts were not on the records of parents and some siblings of children with safeguarding concerns.
• Personnel documentation was not held for all staff.
• Improvements were required to the significant event process.
• Our clinical record searches found improvement was required around monitoring high risk medicines.
• The protocol for monitoring Disease Modifying Anti-Rheumatic Drugs (DMARDs) and high-risk medicines was not effective. There was no robust recall system to ensure that all patients had regular monitoring.

We rated the practice good for providing effective services:

• Patients received effective care and treatment that met their needs.

We rated the practice good for providing caring services:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice requires improvement for providing responsive services:

• The provider did not deal with complaints in accordance with its policy. Complaints were not always appropriately responded to.

We rated the practice requires improvement for providing well-led services:

• Governance structures at the practice were unclear.
• There was no formal agreement in place for two providers working closely together, including sharing staff.
• Most staff told us they had not been involved in developing a vision, values or strategy for the practice.
• There were inaccuracies on the website and some information was outdated.
• Required checks for locum GPs had not taken place.
• There was little evidence that complaints were used to improve the service.
• It was not recorded who was involved in clinical meetings.

We found two breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

• Carry out second cycles of their clinical audits.
• Improve their cervical screening data.
• Add alerts to all family members of children on the safeguarding register.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care