The Care Quality Commission
  • Doctor
  • GP practice

Rocky Lane Medical Centre

Overall: Good read more about inspection ratings

80 Rocky Lane, Liverpool, Merseyside, L16 1JD (0151) 295 3965

Provided and run by:
Rocky Lane Medical Centre

All Inspections

13 July 2023

During an inspection looking at part of the service

We carried out an announced focused inspection at Rocky Lane Medical Centre on 12 July 2023. Overall, the practice is rated as good.

Safe - good

Effective - Not inspected, rating of good carried forward from previous inspection

Caring - Not inspected, rating of good carried forward from previous inspection

Responsive - Not inspected, rating of good carried forward from previous inspection

Well-led - Not inspected, rating of good carried forward from previous inspection

Following our previous inspection on 18 May 2021, the practice was rated good overall and for all key questions aoart from safe, which was rated requires improvement.

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

We carried out this inspection to follow up on:

  • A breach of regulation from a previous inspection on 21 May 2021.
  • The areas identified where the provider should make improvements from the inspection on 21 May 2021.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.

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.

We found that:

  • Action had been taken to address the breach of regulation. The required information to demonstrate high risk medicines were safely monitored was in place.

The provider had also made improvements to the service as recommended in the ‘shoulds’ from the last inspection report.

We found that:

  • Systems were in place to ensure patient records were updated when patient safety alerts were acted upon.
  • Immediately after the last inspection, the practice held meetings with other health professionals such as health visitors. Since this time the meetings have lapsed and been replaced with informal arrangements to discuss patients as needed. Since the last inspection community midwives now attend the practice to see patients.
  • Discussion with patients about do not attempt cardiopulmonary resuscitation (DNACPR), were recorded in the patients records and care plans and the provider told us that patients, families and carers had been involved in conversations about their care, including DNACPR decisions. Despite this a DNACPR order form was not held in the patients record we reviewed.
  • Monitoring systems to ensure patient records were coded correctly were in place.
  • The provider identified reauthorisation and regime dates for medication reviews of patients on long term medicines.
  • The provider had a written agreement in place for GP locums working at the practice.
  • The provider had improved communications with patients by re-establishing a Participation Group.

Whilst we found no breaches of regulations, the provider should:

  • Take further action to establish formal meetings to discuss vulnerable patients with other health professionals.
  • Take action to ensure a DNACPR order form is kept in the patients clinical record.
  • Continue to document in the patient record evidence of effective medicines reviews

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 Health Care

18 May 2021

During an inspection looking at part of the service

We carried out an announced inspection at Rocky Lane Medical Centre on 13 and 18 May 2021. Overall, the practice is rated as Good.

The ratings for each key question we inspected on this occasion are below:

Safe – Requires Improvement

Effective – Good

Well-led – Good

As part of this inspection, we did not inspect the caring and responsive key questions, and their ratings carry forward from the practice’s previous inspection.

Following our previous inspection on 19 November 2019, the practice was rated Requires Improvement overall and the key questions were rated as follows:

Safe – Requires Improvement

Effective – Requires Improvement

Caring - Good

Responsive - Good

Well-led – Inadequate

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

Why we carried out this inspection

The purpose of the inspection was to review the practice CQC rating and regulatory breaches identified at the last inspection as follows:

  • Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
  • Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed
  • Regulation 17 HSCA (RA) Regulations 2014 Good governance

The focus of this inspection also included areas that required improvements in the previous inspection as follows:

  • The provider should further develop their vision for the practice along with a credible strategy to provide high quality sustainable care.
  • Develop a practice Patient Participation Group.
  • Should review the practice arrangements for ensuring staff have access to a Freedom to Speak Up Guardian.

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 Good overall and Requires Improvement for providing safe services. The practice was rated as Requires Improvement for patients whose circumstances make them vulnerable.

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

  • The provider did not operate robust recruitment procedures for GP locums.
  • The processes and monitoring systems in place for prescribing high risk medicines were not robustly operated.

We found that:

  • Patients’ needs were assessed, and care and treatment were delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • The practice had an improved programme of quality improvement and used information about care and treatment to make improvements.
  • Staffing and employment risks management had improved since the last inspection. The management team had planned for and achieved appropriate and safe staffing levels. Recruitment checks for employed staff were carried out in accordance with regulations. Staff had the skills, knowledge and experience to deliver effective care, support and treatment. However, the practice had GPs who worked on a locum basis and there was no written agreement or contract setting out their terms and conditions of working. There was no formal procedure in place for the on-going monitoring of these staff to ensure they were able to provide care and treatment safely.
  • Care was delivered and reviewed in a coordinated way when different teams, services or organisations were involved.
  • The practice actively identified people who may need extra support to live a healthier lifestyle. Staff provided advice and information i.e. leaflets, so people could self-care.
  • The practice had closely monitored the performance targets for long term conditions and at the time of inspection there were improvements in terms of practice performance. We undertook a number of searches of the clinical record system and for a small number of patients we found the correct disease code had not been added to their record. We found the practice was routinely undertaking medication reviews for patients on long term medicines. However, we identified that the practice needed to ensure that onward dates for review had been added to the patient’s records. The practice acted at the time of inspection and addressed the areas we highlighted.
  • The practice understood the needs of its local population and had developed services in response to those needs.
  • The practice had made improvements to the reporting systems for patient complaint and significant event reporting to drive continuous improvement.
  • 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. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The practice had improved the governance structures and systems since the last inspection, and these were kept under regular review.

We found one breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements:

  • Ensure patient records are updated when patient safety alerts are acted upon and discussions with patients have taken place.
  • Develop links with other health and social care professionals such as health visitors, school nurses, community midwives and social workers to support and protect adults and children at risk of significant harm.
  • Discussion with patients about do not attempt cardiopulmonary resuscitation (DNACPR), should be recorded in the patients records and care plans, so that their patients’ needs, wishes and preferences are fulfilled.
  • The provider should develop monitoring systems to ensure that all patients have the correct disease code so that they can be added to the patient recall process and be inbuilt to the practice clinical systems.
  • The provider should identify a reauthorisation and regime date for medication reviews of patients on long term medicines.
  • The provider should ensure that a written agreement or contract is in place for GP locums working at the practice. Formal procedures and monitoring processes should be put into place to ensure safe treatment and care is carried out.
  • The provider should improve communications with patients with re-establishing a Participation Group.

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

19 November 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Rocky Lane Medical Centre on 19 November 2019. We carried out an inspection of this service due to the length of time since the last inspection.

Following our Annual Regulatory Review of the information available to us, including information provided by the practice, we planned to focus our inspection on the following key questions: Safe, Effective and Well-led.

From the Annual Regulatory Review we carried forward the ratings from the last comprehensive inspection for the following key questions: Caring and Responsive.

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 provided the practice with Care Quality Commission feedback cards prior to the inspection. These were given to patients before the inspection and we were informed they had been completed and added to our collection box. On the day of inspection staff reported the box had gone missing along with the comments made by patients. This was reported within CQC as a data security risk.

We have rated this practice as Requires Improvement overall and for all population groups.

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

  • Recruitment checks were not carried out in accordance with regulations. We were unable to verify the level of safeguarding training for all staff.
  • There were no records to demonstrate a fire risk assessment had been completed and no records for fire alarm checks. There were also no records to demonstrate staff had received fire safety training.
  • The practice did not have an automated defibrillator and a risk assessment for this decision was not in place.
  • A number of improvements were needed for the management of medicines related to minor operations procedures.
  • There was a system for recording and acting on significant events. However, the reporting and records made required improvements.

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

  • The practice did not have a comprehensive programme of quality improvement.
  • There was limited evidence to show that quality improvement activity was targeted at the areas where there were concerns.
  • Performance for the management of long term conditions required improving.
  • Appraisals for staff had not been completed annually and no dates were set for this in the near future. Staff files we looked at did not provide the evidence that staff had completed training specific to their role.

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

  • The overall governance arrangements required significant improvements.
  • The practice did not have an effective governance framework to support the delivery of good quality care. There was insufficient evidence to show that information was robust for reporting processes. Information held for significant event reporting, patient feedback, clinical and non-clinical audit findings and risk assessments all required improvements.
  • Policies and procedures essential to good governance were either not in place or were not consistently followed.
  • The management team did not have effective oversight of staff training.
  • The practice did not have an effective system for assessing, monitoring and mitigating the risks related to health safety and welfare of patients and staff.
  • There was limited evidence to show that a comprehensive risk management system was place and regularly reviewed and improved.

The areas where the provider must make improvements as they are in breach of regulations are as follows. The provider must:

  • 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.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements as they are in breach of regulations are as follows. The provider should:

  • The provider should further develop their vision for the practice along with a credible strategy to provide high quality sustainable care.
  • Develop a practice Patient Participation Group.
  • Should review the practice arrangements for ensuring staff have access to a Freedom to Speak Up Guardian.

(Please see the specific details on action required at the end of this report).

These areas affected all population groups, so we rated all population groups as Requires Improvement.

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

23 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Rocky Lane Medical Centre on 29 October 2014 and at this time the practice was rated as good. However, breaches of legal requirements were also found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

  • Regulation 21 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014;

During the inspection there were a number of areas that required improvement also and we identified that the provider should:

  • Ensure annual electrical tests are completed for all electrical equipment in use.

  • Ensure doctors have available emergency drugs for use in a patient’s home.

  • Have available the use of equipment such as pulse oximeters, defibrillators and oxygen for emergency treatments in line with current external guidance and national standards.

On the 23 April 2016 we carried out a focused desk top review of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The review was carried out to check whether the provider had completed the improvements identified during the comprehensive inspection carried out in October 2014. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Rocky Lane Medical Centre on our website at www.cqc.org.uk.

The findings of this review were as follows:

  • The practice had addressed all of the issues identified during the previous inspection.

  • Improved systems had been put into place to ensure that staff were not allowed to undertake a chaperoning role without the necessary checks having been received.

  • Arrangements were put into place to ensure that GPs had access to emergency drugs for use in the patient’s home and these were in regular review.

  • The practice had equipment available to respond appropriately to a sudden deterioration in a patient’s health and a medical emergency situation. However the practice continues to operate without an automated defibrillator for emergency purposes.

There remain areas where the provider should make improvements as follows:

  • The provider should ensure that an automated patient defibrillator is available for use in an emergency situation, in line with current best practice guidelines.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

29 November 2014

During a routine inspection

This is the report of findings from our inspection of Rocky Lane Medical Centre. The practice is registered with the Care Quality Commission (CQC) to provide primary care services. We undertook a planned, comprehensive inspection on 29 October 2014 and we spoke with patients, relatives, staff and the practice management team.

The practice was rated as Good.

Our key findings were as follows:

  • Staff understood and met their responsibilities to raise concerns and report incidents, risks and near misses. Lessons were learned and communicated widely to support improvement. There were enough staff to keep people safe. However improvements were required to ensure staff were safely recruited and required information was held in relation to staff.
  • Patient’s needs were assessed and care was planned and delivered in line with current legislation. Staff received training appropriate to their roles and further training needs have been identified and planned.
  • Many patients told us they were treated with compassion, dignity and respect and that they were involved in care and treatment decisions.
  • The practice reviewed the needs of their local population. Patients reported good access to the practice.
  • There was a clear leadership structure and staff felt supported by management. There were systems in place to monitor and improve quality and identify risk.

There were areas of practice where the provider needs to make improvements. 

The provider must:

  • The provider must ensure that all staff with chaperoning responsibilities have had a Disclosure and Barring Service (DBS) check completed. 

The provider should:

  • Ensure annual electrical tests are completed for all electrical equipment in use.
  • Ensure doctors have available emergency drugs for use in a patient’s home.
  • Have available the use of equipment such as pulse oximeters, defibrillators and oxygen for emergency treatments or a risk assessment in place supporting their decision not to have this.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice