27 July 2022
During a routine inspection
We carried out an announced inspection at The Highlands Practice on 27 July 2022. Overall, the practice is rated as Requires Improvement.
Safe - Requires Improvement
Effective - Requires Improvement
Caring - Good
Responsive - Requires Improvement
Well-led – Requires Improvement
The provider of this service has changed since our previous inspection on 7 May 2019 where we rated the service Good overall and for all key questions. This inspection in July 2022 is the first under the provider’s new registration, which incorporates two branch practices, Jubilee Surgery and Whiteley Surgery since the merger in October 2021.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Highlands Practice on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive risk-based inspection undertaking a site visit and remote clinical searches to review:
- Safe, Effective, Caring, Responsive, Well-led domains
- Risks identified in relation to patient access through complaints to CQC.
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 facilities
- Completing remote 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 to all three sites
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 found that:
- The practice provided care that did not always keep patients safe. In particular, high-risk medicine monitoring; unclear medicine review records and actioning safety alerts.
- Patients did not always receive effective care and treatment that met their needs. In particular, outstanding monitoring of patients with long-term conditions.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. However, patients could not always access care and treatment in a timely way.
- Governance processes were in place but oversight of risk management to patient safety and providing effective services was not always fully embedded.
We found breaches of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
- Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, supervision and appraisal necessary to enable them to carry out their duties.
- Establish effective systems and processes to enable person-centred care for people using the services.
The provider should also:
- Implement new ways for patients to access appointments at the practice.
- Improve the uptake of cervical cancer screening to eligible patients.
- Continue to respond to complaints in a timely way and maintain a full audit trail of correspondence relating to all complaints.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services