We carried out an announced comprehensive inspection of Dr Poolo’s Surgery – Rush Green Medical Centre on 30 September 2021.
Following our previous inspection on 22 February and 9 and 10 March 2021, the practice was rated as inadequate overall (inadequate for ‘Safe’, ‘Effective’ and ‘Well-led’, and ‘Caring’ and ‘Responsive’ were not inspected so the previous rating of good was carried over).
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Poolo’s Surgery – Rush Green Medical Centre on our website at www.cqc.org.uk.
Throughout the COVID-19 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 reduced 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 by email; and
- A site visit to the practice.
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.
At this inspection, we have rated the practice as requires improvement overall.
We rated the practice as requires improvement for providing safe services because:
- The practice did not have an induction checklist for clinical staff and there was no locum handbook for locum GPs to refer to.
- No risk assessment had been completed to support the practice’s decision that basic life support training would not be completed annually, as per Resuscitation Council UK guidelines.
- The practice was not able to provide a Patient Group Direction for a specific vaccine.
- The significant events policy was not being followed consistently by staff, in terms of the formal reporting mechanisms.
- The system to monitor cervical screening results was ineffective and required further oversight.
- There was no system in place to monitor and track blank prescriptions throughout the practice.
- We saw no evidence that the practice had warned patients about a medicine’s particular risks, as specified in a safety alert.
- However, we found that the practice had addressed issues from our previous rated inspection, and we saw appropriate arrangements for monitoring and safeguarding patients at risk, structured and appropriately documented medication reviews, appropriate monitoring for patients prescribed high-risk medicines, and no prescribing of medicines contrary to safety alerts.
We rated the practice as requires improvement for providing well-led services because:
- There was limited documented evidence of compliance with the duty of candour for the two most recent significant events.
- Some policies were not specific to the practice, were missing some information, were not version-controlled or did not have a next review date.
- The shared drive containing the practice’s policies and procedures was disorganised and required review, with some staff not able to locate certain policies or up to date versions of documents.
- Some meeting minutes did not contain any detail of what was discussed, and there was no formal system to ensure actions were consistently followed up.
- There were some gaps in monitoring and management systems, including oversight of cervical screening results, monitoring of blank prescriptions, authorisation of medicines, and COSHH.
- However, leaders had taken action to address the risks we had identified at the previous CQC inspection, for example in relation to monitoring of patients, management of long-term conditions, clinical record keeping, safeguarding arrangements, oversight of healthcare staff, and recruitment checks.
We rated the practice as good for providing effective services because:
- Our records review indicated that care and treatment was delivered in line with current standards and evidence-based guidance.
- We did not see any instances of a failure to follow up on symptoms indicating possible serious illness.
- The practice had carried out audits looking at its care of patients with specific long-term conditions, and this had improved since the previous inspection.
- Clinical staff had completed role-specific training and staff had access to regular appraisals and clinical supervision.
- We saw that record keeping had improved, with clear documented reviews and assessments by GPs. The practice had increased its use of clinical templates which helped to ensure that structured reviews and consultations were completed.
- Do Not Attempt Cardiopulmonary Resuscitation decisions were made in line with relevant legislation and were appropriate.
- These areas affected all population groups, so we rated all population groups as good for providing effective services, except for the population group ‘working age people’ which we rated requires improvement as the system to monitor cervical screening results was ineffective and required additional oversight.
We rated the practice as good for providing caring services because:
- Staff treated patients with kindness, respect and compassion.
- Feedback we received from the Patient Participation Group (PPG) advised that the practice meets the needs of and listens to its patients.
- The practice’s GP patient survey results for 2021 were in line with national averages for questions relating to kindness, respect and compassion.
- The practice respected patients’ privacy and dignity.
We rated the practice as good for providing responsive services because:
- The practice’s GP patient survey results for 2021 were in line with national averages for questions relating to access to care and treatment, except for the question about telephone access which was better than the national average.
- We checked the appointment system and saw there were routine and urgent GP appointments available quickly.
- Feedback we received from the Patient Participation Group (PPG) and staff we spoke with said that patients were able to access appointments.
- We saw evidence of compliance with the Accessible Information Standard and arrangements in place for patients’ particular needs.
- Complaints were listened and responded to and used to improve the quality of care.
- These areas affected all population groups, so we rated all population groups as good for providing responsive services.
The areas where the provider should make improvements are:
- Review the necessity to carry out checks of clinicians’ registration on an ongoing basis throughout their employment.
- Consider merging the checklist of emergency medicines, refrigerated vaccines and emergency equipment, to make the checking process easier and more efficient for staff members.
The areas where the provider must make improvements are:
- Ensure care and treatment is provided in a safe way to patients.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
(Please see the specific details on action required at the end of this report).
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.
Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care