Oakfield Health Centre, Practice 2

We carried out an announced inspection at Oakfield Health Centre. We conducted remote clinical searches on the practice’s computer system on 3 August 2022 and conducted an onsite inspection of the practice on 4 August 2022 under Section 60 of the Health and Social Care Act 2008, as part of our regulatory functions.

The key questions at this inspection are rated as:

Safe – Requires Improvement

Effective – Requires Improvement

Responsive - Good

Well-led – Requires Improvement

Following our previous inspection on 10 January 2017, the practice was rated Good overall and for all key questions.

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

Why we carried out this inspection

This inspection was a focused comprehensive inspection to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection focused on the following:

• Are services safe?
• Are services effective?
• Are services responsive in relation to access?
• Are services well-led?

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 Requires Improvement overall.

We rated the practice as Requires Improvement for providing safe services because:

• Appropriate standards of cleanliness and hygiene were met. However, improvements were required.
• Staff had the information they needed to deliver safe care and treatment. However, improvements were required. For example, oversight of the task and document management system.
• Improvements were required in relation to the monitoring and assessment of patients’ health in relation to the use of high-risk medicines.
• Improvements were required in relation to the monitoring of medicines that required refrigeration.
• The practice did not have a documented risk assessment in place relating to some recommended emergency medicines that were not held in the practice. The practice stocked the medicines within 48 hours after the inspection.
• Improvements were required in relation to documenting evidence of learning and dissemination of information.
• Systems for managing safety alerts were not always effective.

We rated the practice as Requires Improvement for providing effective services because:

• Patients’ needs were not always assessed, and care and treatment were not always delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
• Performance relating to cervical cancer screening required improvement.

We rated the practice as Requires Improvement for providing well-led services because:

• There were processes for managing risks, issues and performance. However, these were not always effective.

The provider sent evidence to show they had remedied the above findings within 48 hours after the inspection.

The areas where the provider must make improvements are:

• 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:

• Continue to monitor and check that systems for the monitoring of medicines that require refrigeration are adhered to.
• Continue to implement and monitor the outcome of plans to improve performance relating to the uptake of childhood immunisations and cervical cancer screening.
• Continue to embed processes to ensure learning and dissemination of information is documented in relation to significant events.
• Review processes to ensure accurate read coding within patient care records.

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