We carried out an announced inspection at The Community Practice on 29 November 2021 Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Requires Improvement
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
This was the first time that this practice has been inspected.
Why we carried out this inspection
This was a comprehensive inspection undertaken as part of our inspection programme.
How we carried out the inspection
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 staff interviews using video conferencing
- 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 found that:
- The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm. We found that not all medicines reviews were carried out in line with guidance. We also found that safety alerts had not been acted upon.
- The practice system for acting on patient safety alerts needed strengthening
- The practice system for identifying patients with a possible diagnosis of diabetes needed strengthtening.
- The practice performance for the prescribing of anti-microbials needed strengthening.
- The uptake for cervical screening and some childhood immunisations needed improvement.
- Patients received effective care and treatment that met their needs. The patient records that we reviewed remotely demonstrated that care pathways and protocols were managed well.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care. We saw that staff at the practice worked closely with the palliative care team so that patients at end of life received the best care possible.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care. The vision of the practice was to be at the heart of the local community and staff were involved in projects led by the local community.
Whilst we found no breaches of regulations, the provider should:
- Improve the process for all medicines reviews in line with guidance.
- Improve the process for acting on patient safety alerts in line with guidance.
- Improve the process for identifying and coding patients with a possible diagnosis of diabetes.
- Continue to improve performance for the prescribing of anti-microbials.
- Continue to improve the uptake of cervical screeening.
- Continue to improve the uptake of childhood immunisations.
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