Background to this inspection
Updated
9 June 2021
Elbury Moor Medical Centre is located in South Worcestershire. The practice has good transport links and is situated in purpose-built premises which also accommodates a pharmacy.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening
procedures, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures.
Elbury Moor Medical Centre is a member of the South Worcestershire Clinical Commissioning Group (CCG) and provides services to patients under the terms of a general medical services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community. At the time of our inspection there were approximately 12,000 patients registered at the practice.
Information published by Public Health England, rates the level of deprivation within the practice population group as three, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.
The practice has six GP partners, one salaried GP, one Retained GP, a clinical pharmacist, one advanced nurse practitioner, two practice nurses, one assistant practitioner and two healthcare assistants. The clinical team is supported by a practice manager, a team of administrative, reception supervisors and reception staff.
The practice is open between 8am and 6.30pm Monday to Friday with extended hours on Monday 8am until 8pm and Tuesdays 7am until 6.30pm. Home visits are available for patients who are too ill to attend the practice for appointments.
The practice does not provide out of hours services to their own patients. When the practice is closed patients are directed to contact Care UK via NHS 111.
The practice website can be viewed at: www.elburymoor.co.uk.
Updated
9 June 2021
We carried out an announced follow up inspection at Elbury Moor Medical Centre on 17 and 18 May 2021. The practice had previously been rated Requires Improvement. At the last inspection in October 2019, we identified the following areas for improvement:
- Continue to work on reducing the prescribing of hypnotics and antibiotics.
- Continue work to increase the uptake for cervical, breast and bowel screening.
- Continue with actions to increase the uptake for immunisations.
- Continue to take actions to improve performance and ensure patients receive care and treatment that meets their needs.
- Continue to take steps to increase an audit programme of quality improvement.
We found the practice had made improvements at this inspection.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Elbury Moor Medical Centre on our website at www.cqc.org.uk
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 record system & 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 provided care in a way that kept patients safe and protected them from avoidable harm.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice had identified 2% of patients who were also carers and had updated its carers’ register accordingly.
- The practice’s Patient Participation Group were positive about their relationship with the practice. They felt supported, appreciated and listened to.
- The practice now had a comprehensive system in place to learn from significant events and complaints.
- The practice had completed several two cycle audits over the last 12 months to improve outcomes for patients including a two week wait audit.
- At the last inspection the low rates of cervical screening and childhood immunisations were reasons for the practice being rated Requires Improvement overall. Whilst the practice has taken action to improve in these areas this has not shown in the data yet.
- During the clinical searches we completed as part of our inspection we found a couple of patients who had not been coded appropriately. We are assured that they have received adequate care and treatment.
- The quality outcomes and framework data for patients who had respiratory problems was lower than national and CCG average. The practice had identified this and had recruited a respiratory nurse.
Whilst we found no breaches of regulations, the provider should:
- Continue to improve its cervical screening uptake rates.
- Continue to improve its childhood immunisations uptake rates.
- Review the electronic patient system to ensure that all patients are coded correctly.
- Continue to monitor annual reviews for respiratory patients.
- Review formal training procedures for cleaning staff and continue to check that cleaning schedules are completed.
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