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Dr Christopher John George Wright Good Also known as Deerbrook Surgery

Inspection Summary


Overall summary & rating

Good

Updated 8 July 2021

We carried out an announced inspection at Dr Christopher John George Wright (also known as The Deerbrook Surgery) on 26 May 2021. Overall, the practice is rated as Good.

Safe - Requires improvement

Effective - Good

Well-led - Good

Following our previous inspection on 22 to 23 October 2019, the practice was rated requires improvement overall and good for the key questions caring and responsive. The practice was rated as requires improvement for providing safe, effective and well-led services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Christopher John George Wright on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection to follow up on breaches of Regulation 12 Safe care and treatment and Regulation 17 Good governance. At the previous inspection we found:

  • There was no formal process for reviewing patients prescribed one high risk medicine to monitor their health.
  • There was no system in place to ensure blood test referrals were completed or recorded accurately.
  • There was limited action taken in response to the lack of clinical and non-clinical staff reported by staff.
  • The leadership governance and culture did not always support the delivery of high-quality person-centred care. The arrangement for governance and performance management was not fully clear or did not always operate effectively.

We also followed up on areas we identified the practice should improve at the last inspection. Specifically to:

  • Undertake an assessment of how clinical incidents can be identified, recorded and analysed for improvements.

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 have rated this practice as good overall and requires improvement for the key question safe and for the population group people with long-term conditions.

We found that:

  • The practice had systems for the appropriate and safe use of medicines in most respects. However, the practice had not undertaken required monitoring for three patients prescribed one high-risk medicine.
  • The provider did not stock all medicines recommended for treating medical emergencies and they did not have appropriate risk assessments in place to justify these ommisions.
  • Although the practice had processes in place to respond to safety alerts, they were not always effective.
  • The practice had a system in place for ensuring that clinical staff were registered and indemnified; however, we found one instance where this was not effective.
  • The cleaning checklist had not been completed by cleaning staff; and the mops in the cleaning cupboard had not been stored properly and in accordance with the colour codes assigned to each cleaning area.
  • The practice had above average exception reporting for patients with some long-term conditions.
  • 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.
  • 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-centre care.
  • There was a clear leadership structure and staff felt supported by management.
  • There was evidence of quality improvement activity.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Review the process for monitoring indemnity arrangements and professional registrations of clinical staff.
  • Implement a cleaning schedule to be assured that appropriate standards of cleanliness and hygiene are met.
  • Continue efforts to reduce higher than average rate of exception reporting and improve clinical outcomes for patients with long term conditions to be assured that conditions are being well-managed.
  • Continue efforts to improve rates of cancer screening and childhood immunisation uptake.

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

Inspection areas

Safe

Requires improvement

Effective

Good

Caring

Good

Responsive

Good

Well-led

Good
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good