Gateacre Brow Practice

We carried out an announced inspection at Gateacre Brow Practice on 19, 23 and 24 November 2021 Overall, the practice is rated as Requires Improvement.

The ratings for each key question are as follows:

Safe - Requires Improvement

Effective – Requires Improvement

Caring – Good

Responsive – Requires Improvement

Well-led - Requires Improvement

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Following our previous inspection on 15 December 2015, the practice was rated good overall.

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

Why we carried out this inspection

This inspection was a comprehensive review of information which included a site visit.

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 practice 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.

The practice is rated as requires improvement for providing safe services because:

• Recruitment checks were partially carried out in accordance with regulations.
• Systems and processes to monitor significant event occurrences were ineffective.
• There was limited evidence of learning and dissemination of information for the management of significant events.
• The systems in place for monitoring patients’ health in relation to the use of medicines including high risk medicines, were ineffective.

The practice is rated as requires improvement for providing effective services because:

• The management of patients with long term conditions required improvements.
• There was some monitoring of the outcomes of care and treatment however, this was limited.
• Staff did not have access to regular appraisals, one to ones and clinical supervision.
• The practice could not demonstrate how they assured the competence of staff employed in advanced clinical practice.
• Records to show Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions required improvements.

The practice is rated as good for providing caring services because;

• Staff treated patients with kindness, respect and compassion. Feedback from patients was positive about the way staff treated people.
• Patient feedback about how caring staff were was positive.

The practice is rated as requires improvement for providing responsive services because;

• There was insufficient evidence that complaints were used to drive continuous improvement.
• Patient satisfaction with telephone access to the practice was poor.

The practice as requires improvement for providing well led services because;

• Staff reported that leaders were always not visible.
• The practice did not have access to a Freedom to Speak Up Guardian.
• Governance structures and systems such as incident reporting, staff recruitment and the management of patient complaints were not monitored effectively.
• The provider’s supervision and support arrangements for staff required improvements.
• There was evidence of some audit activity carried out by the practice. However, there was no formal quality improvement programme in place.

We found three breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients
• Establish effective processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

The provider should:

• Review how patient views are acted on to improve services and culture.
• Review and improve telephone access to the practice.
• Continue to monitor and take actions to improve the uptake for cervical cancer screening for women at the practice.

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