Edge Hill Health @ Mossley Hill Surgery

We carried out an announced inspection at Edge Hill Health @ Mossley Hill Surgery across 13-15 September 2021. Overall, the practice is rated as Good.

Safe - Good

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 14 August 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 – Requires Improvement

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Edge Hill Health @ Mossley Hill Surgery on our website at www.cqc.org.uk

Why we carried out this inspection/review.

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 13 HSCA (RA) Regulations 2014 Safeguarding service users from abuse and improper treatment
• Regulation 17 HSCA (RA) Regulations 2014 Good governance
• Regulation 18 HSCA (RA) Regulations 2014 Staffing

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 Good for all population groups.

We found that:

• The practice had clearer systems, practices and processes to keep people safe and safeguarded from abuse. This included a safeguarding lead GP and improved systems and processes for monitoring patients at risk.
• Recruitment checks were carried out in accordance with regulations (including for agency staff and locums).
• Since the last inspection the practice had been redecorated and some improvements to the building were made.
• Effective measures were put in place to minimise the risk presented by the Covid-19 pandemic.
• The process for the monitoring patients’ health in relation to the use of medicines including high risk medicines had improved. However, We looked at a sample of patients prescribed these medicines on the recall system and registers introduced by the practice. We found that a small number of patients had not benefited from the new monitoring systems.
• The arrangements for identifying, recording and managing risks, issues and mitigating actions had improved since the last inspection.
• 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.
• Staff had the skills, knowledge and experience to deliver effective care, support and treatment.
• We found that leaders were compassionate, inclusive and effective and staff we spoke with told us they were visible, approachable and supportive. We heard there was a strong emphasis on the safety and well-being of staff, particularly during the Covid-19 pandemic.
• Since the last inspection clearer responsibilities, roles and systems of accountability to support good governance and management had been introduced. This included improved processes for managing risks, issues and performance.
• The practice had systems in place to continue to deliver services, respond to risk and meet patients’ needs during the Covid-19 pandemic
• The practice did not have a Patient Participation Group. Patient views had not been formally collated across the pandemic and the Friends and Family survey had been suspended. At the time of the inspection this had been recommenced.
• Staff reported that there had been improvements to communication and their involvement in the operation of the service. Staff meetings were now held more frequently, and the staff spoken with felt able to give their views at these meetings. Increased support systems had been put in place so that staff did not feel isolated from the main provider practice at Edge Hill Health Centre.

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

• Review how patient views are gathered and acted on to improve services and culture.
• Ensure that all staff who have direct contact with patients are be able to demonstrate their vaccination status.
• Continue to monitor the uptake of the practice cervical screening programme.

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