Yellow Practice

We carried out an announced inspection at Yellow Practice from 18 October to 21 October 2021. Overall, the practice is rated as Requires improvement.

The key questions are rated as

Safe - Requires improvement

Effective - Requires improvement

Caring - Good

Responsive - Good

Well-led - Inadequate

At our previous inspection in May 2019 we identified breaches of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and issued a requirement notice. The practice was rated as requires improvement for providing safe services. It was rated as good overall and good for providing effective, caring, responsive and well led services. Following our inspection we were provided with an action plan detailing how the practice planned to make the required improvements.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Yellow Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this comprehensive follow-up inspection to confirm that the service now met the legal requirements in relation to those breaches of regulation and to ensure sufficient improvements had been made. We looked at whether the practice was providing safe, effective, caring, responsive and well-led services in response to concerns about the practice.

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 the 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 as inadequate for providing well led services due to insufficient improvements made since our previous inspection and newly identified breaches of regulation.

We found that:

• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect.
• Patients prescribed methotrexate (an immune-system suppressant) were now appropriately monitored.
• Clinical staff now complied with the practice policy of ‘bare below the elbows’.
• Clinical waste was now appropriately segregated.
• The monitoring of fridge temperatures continued to fail to ensure the safe storage of medicines.
• The security of blank prescription forms was still not in line with current guidance.
• Patient Group Directions (PGDs) continued to be incorrectly completed and did not ensure the safe administration of those medicines to selected patients.
• There was a lack of monitoring of staff immunisations.
• Infection prevention control audits were invalid as staff lacked the knowledge and understanding to accurately complete them.
• Recruitment records were incomplete and did not ensure the safe recruitment of staff.
• The practice had failed to identify or assess the risks associated with the Control of Substances Hazardous to Health (COSHH).
• Organisational policies did not always contain accurate or up to date information to ensure appropriate guidance for staff.
• Staff had not recently undergone appraisal or interim performance review.
• Significant event reporting processes were not clearly understood or implemented.
• Processes for identifying and managing risk were not always clear or working as intended.
• Practice premises were poorly maintained and presented potential risks to staff and patients.
• Leaders had insufficient oversight in order to identify when processes were not working as intended.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Ensure all premises and equipment used by the service provider is fit for use.
• 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:

• Develop confidentiality sharing agreements with all co-located services.
• Undertake completed two-cycle clinical audits to enhance monitoring of care and treatment outcomes.

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