All inspections: OHP-Poolway Medical Centre

We carried out an announced inspection at OHP-Poolway Medical Centre on 09 August 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

Following our previous inspection on 5 February 2020, the practice was rated Requires Improvement overall and Good for three key questions but requires improvement for providing responsive and well-led services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for OHP-Poolway Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive follow-up inspection to follow up on:

Key questions inspected
Breaches of regulations and ‘shoulds’ identified in previous inspection
Information received from stakeholders as well as feedback relating to patients’ experience
Ratings carried forward from previous inspection

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 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 have rated this practice as Good overall and good for all population groups; except, families, children, and young people population group which we rated requires improvement.

We found that:

Prescribing data showed significant improvements in relation to antibiotic prescribing over the previous 12 months. Patients treatment plans were adjusted as well as referrals to services to support patients with non-clinical interventions to manage pain.
Data showed that the practice uptake of childhood immunisation continued to remain below national targets.
The practice was not meeting national targets for cervical cancer screening uptake.
Data from the March 2020 national GP survey indicated that patient satisfaction was comparable to local services. However, feedback and comments placed on various platforms showed that patients were less positive about staff attitudes and getting through to the practice by phone.
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 range of ways such as video consultations.
The practice did not have an effective system for the oversight and monitoring of quality assurance, including clinical audit.

We rated the practice as requires improvement for providing safe services because:

The practice did not have an effective system for monitoring the recruitment process; in particular gaining assurance that clinical staff who were employed through a recruitment agency had completed training and demonstrated they were skilled and competent to carry out their role.
There was a lack of an effective system to manage patient safety alerts as well as ensuring routine application of national guidelines.
The monitoring of significant events did not routinely demonstrate that actions identified by the provider to remedy the situation had been completed in their entirety.

We found a breach of regulations. The provider must:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

We also found areas where the provider should improve:

Continue taking action to improve the uptake of childhood immunisation and accuracy of data; as well as improving the uptake of cervical screening.

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

We carried out an announced comprehensive inspection at OHP-Poolway Medical Centre on 5 February 2019 as part of our inspection programme.

The practice was previously inspected on the 15 January 2019 and received a rating of requires improvement overall. At this inspection we followed up on breaches of regulations identified at a previous inspection on 15 January 2019.

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 and requires improvement for all population groups.

We rated the practice as good for providing safe, effective and caring services.

The practice provided care in a way that kept patients safe and protected them from avoidable harm.
Patients received effective care and treatment that met their needs.
Clinical staff were knowledgeable about their patients care and treatment needs and responded to those needs as appropriate.
We received positive feedback about the kindness and respect shown by the principal GP in particular and most staff however, this was not consistently the case.
However, results from the latest GP national patient survey had fallen since our previous inspection in relation to questions about consultations.

We rated the practice as requires improvement for providing responsive and well-led services.

At our last inspection we found the practice governance arrangements were not effective in supporting high quality sustainable care. At this inspection we found the practice had implemented a more structured approach for the governance of the service and for management of information. However, we continued to identify concerns relating to the governance of the practice that were not embedded.
Risks relating to staff workloads were not being effectively managed.
We found greater awareness of incident reporting since our last inspection however, we identified incidents that were not reported and evidence of repeated incidents which lacked effective learning to support continued improvements.
Although there was some improvement in patient satisfaction relating to access these were still below local and national averages.
Systems and processes for managing complaints and staff appraisals were not always appropriate or effective.
The practice culture did not always effectively support high quality sustainable care.

These areas affected all population groups so we rated all population groups as requires improvement.

The areas where the provider must make improvements are:

Ensure there is an effective system for identifying , receiving ,recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

Improve systems for monitoring and ensuring locum staff have completed relevant training.
Review action taken to improve the uptake of cervical screening and childhood immunisations and identify ways this may be further improved.
Improve the identification of carers and accuracy of the carers register to enable this group of patients to access the care and support they need.
Continue to review action to improve patient satisfaction, in order to deliver further improvements. Including systems for raising awareness of online services.
Review systems for the cleaning of clinical equipment.

We saw an area of outstanding practice:

The practice did a weekly round of home visits to patients on their palliative care register who were housebound to ensure their continued needs were being met.

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

We carried out an announced comprehensive inspection at OHP-Poolway Medical Centre on 15 January 2019 as part of our inspection programme.

The practice was previously inspected under the previous provider in November2017 and was rated good overall with a Requires improvement in Responsive.

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 have rated all population groups as requires improvement.

We rated the practice as requires improvement for providing safe, responsive and well-led services because:

The overall governance arrangements to support high quality sustainable care was not effective.
Management information was not always readily available when required.
Not all staff were fully aware of policies and procedures in place and many of these were under review.
Risks were not always effectively considered and mitigated against.
Prescription pads were not kept fully secured and the management of prescription pads was not effective as there was no auditable process to prevent misuse.
Systems for recording and reporting incidents were not clearly embedded throughout the practice.
Patient feedback from the national GP survey shows that patients were happy with their consultations. However, experience of making an appointment and satisfaction with appointment times were significantly below local and national averages.

We rated the practice as good for providing caring and effective services because:

Patients received effective care and treatment that met their needs.
Staff dealt with patients with kindness and respect and involved them in decisions about their care.

The areas where the provider must make improvements are:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

Improve knowledge and understanding in relation to incident reporting.
Review the accuracy of the carers register to ensure support is appropriately targeted.
Consider how the practice could support improved uptake of all national cancer screening programmes.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This practice is rated as Good.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students) – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at OHP-Poolway Medical Centre on 10 November 2017 as part of our inspection programme.

At this inspection we found:

The practice was faced with a number of challenges outside their control which had placed additional pressure on staff and the service. This included two practice relocations since registering with CQC and the long term leave of one of the partners. The latest relocation of services was in September 2017. These challenges had generally been well managed by the practice to ensure continuity of service provision.
The practice had systems and processes in place to keep patients safe and safeguarded from abuse. This included safeguarding arrangements, management of infection control, medicines and for unforeseen events.
At the time of our inspection, the tenancy agreement was due to be signed and the practice was working with the landlord to ensure the safety of the premises. Refurbishment was in progress and various risk assessments had been undertaken in relation to the premises.However, we found risk assessments in relation to fire safety were not sufficiently detailed and were in need of review.
The practice was reliant on regular locum staff , The principal GP worked flexibly to ensure cover was provided.
The practice ensured that care and treatment was delivered according to evidence- based guidelines. They worked with a range of health and care professionals in the delivery of patient care.
Patient outcomes in relation to the quality outcome framework showed the practice was performing in line with other practices locally and nationally for many long term conditions.
Feedback from patients from the national GP patient survey and the CQC patient comment cards showed that they felt they were treated with compassion, kindness, dignity and respect and felt involved in their care and treatment. Patient satisfaction with consultations with clinical staff and helpfulness of reception staff was above local and national averages.
However, patient feedback also indicated that they did not always find it easy to access care when they needed it. The practice had started making improvements such as the recent piloting of a new telephone systems.
We found systems for record keeping to support the delivery of the service was not always effective for example the recording of action taken in response to safety alerts, information relating to staff including training and registration and meetings.

The areas where the provider should make improvements are:

Review systems and processes for recording incidents occurring within the practice (positive and negative) to support practice learning.
Review systems for monitoring staff registration with professional bodies to ensure they remain up to date.
Review fire safety in the premises to ensure an adequate assessment of risk has been undertaken and action taken in response.
Improve record keeping in relation actions taken in response to staff training, staff information, practice meetings and safety alerts.
Take action to address areas where the practice is an outlier in relation to patient outcomes and prescribing.
Continue to take action for improving patient satisfaction in relation to access to appointments and monitor progress to ensure progress is being made.
Make greater use of service improvement activity such as clinical audit to support service improvements.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Archived: OHP-Poolway Medical Centre

All Inspections

9 August 2021

During a routine inspection

5 February 2020

During a routine inspection

15 January 2019

During a routine inspection

10 November 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)