Background to this inspection
Updated
30 June 2021
Nutgrove Villa Surgery is located at:
Nutgrove Villa
Westmoreland Road
Huyton
Liverpool
Merseyside
L36 6GA
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, treatment of disease, disorder or injury and surgical procedures.
The practice is situated within the Knowsley Clinical Commissioning Group (CCG) and delivers Personal Medical Services (PMS) to a patient population of about 3,750. This is part of a contract held with NHS England.
The practice is part of a wider network of ten other GP practices.
Information published by Public Health England report deprivation within the practice population group as 1 on a scale of 1 to 10. Level one represents the highest levels of deprivation and level 10 the lowest.
The practice has a higher number of working age people registered at the practice similar to the Clinical Commissioning Group (CCG) and England average.
The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.
The practice has a team of two partner GPs, one practice nurse who provides nurse led clinics for long-term conditions. The GPs are supported at the practice by a practice manager, deputy practice manager and a team of reception staff. A clinical pharmacist is contracted from a local pharmacy with assistance from the Primary Care Network (PCN) pharmacists.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations.
In addition to the extended hours operated by the practice, patients can access a walk-in service and out-of-hours service situated at the Nutgrove Villa resource centre which is in the same building as the GP practice.
Updated
30 June 2021
Following our previous inspection on 21 March 2019, the practice was rated Requires Improvement overall and for safe, effective and well led key questions and good for caring and responsive.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Nutgrove Villa Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused inspection looking at safe, effective and well led, with the previous ratings for caring and responsive carried forward.
We reviewed the breaches identified at the last inspection:
Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment. The regulation was not being met because:
- The provider had failed to ensure the proper and safe management of medicines: Adrenaline was not available in the rooms in which babies were immunised.
- The provider had not carried out a risk assessment in relation to the emergency medicines which were not stocked.
- The provider had not risk assessed the systems in place to ensure baby immunisations were conducted in keeping with best practice guidance.
- Systems were not in place to comprehensively monitor prescribing and the provider did not audit the prescribing of controlled medicines.
- The provider did not have a documented approach for the management of requesting tests and the process for how to handle test results was not made familiar to all members of the practice team.
- The provider did not have safe systems in place for referrals to secondary medical care.
- The timeliness and take-up of routine referrals was not monitored.
- Audits that had been completed did not provide information about the safety of the service provided or the outcomes for patients.
- Sample takers had not audited their results.
Regulation 17 HSCA (RA) Regulations 2014 Good governance How the regulation was not being met:
- There was a lack of systems and processes established and operated effectively to ensure compliance with requirements to demonstrate good governance. There was failure to ensure the audit and governance systems were effective.
- The provider did not have an audit program to review the care and treatment provided by clinicians.
- There was no clinical oversight relating to outcomes for patients.
- The provider did not have an audit program in place to review the effectiveness and staff compliance with the policies and procedures in place.
We also reviewed the areas where the previous inspection identified that the provider should make an improvement by:
- Audit whether consent to treatment is always legally obtained.
- Review system or policies to manage uncollected prescriptions.
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 key questions and population groups.
We found that:
- The breaches of Regulation 12 Safe care and treatment had been addressed and changes had been made to policies and procedures. Patients received effective care and treatment that met their needs.
- The breaches of Regulation 17 Good governance had been addressed by revising the governance structure, processes and procedures. The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
Whilst we found no breaches of regulations, the provider should:
- Obtain up to date references and DBS checks for new members of staff.
- Audit patient records to check information is recorded accurately.
- Record mental capacity assessment for DNACPR in electronic record as well as the required paper record.
- Continue to improve breast screening 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