The Care Quality Commission
  • Doctor
  • GP practice

Archived: The Village Medical Centre

Overall: Requires improvement read more about inspection ratings

Kingswood Way, Great Denham, Bedford, Bedfordshire, MK40 4GH (01234) 244000

Provided and run by:
Innovation Healthcare Solutions Limited

Important: The provider of this service changed. See old profile

All Inspections

12 November 2020

During a routine inspection

We carried out an announced comprehensive inspection at The Village Medical Centre on 27 February 2020. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, as part of our regulatory functions. The overall rating for the practice was inadequate and the practice was placed into special measures for a period of six months. The full comprehensive reports of the February 2020 inspection can be found by selecting the ‘all reports’ link for The Village Medical Centre on our website at www.cqc.org.uk

This announced comprehensive inspection on 10 to 12 November 2020 was carried out following the period of special measures to ensure improvements had been made and to assess whether the practice could come out of special measures.

We took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering how we carried out this inspection. We therefore undertook some of the inspection processes remotely and spent less time on site. We conducted staff interviews remotely on 10 to 11 November 2020 and carried out a site visit on 12 November.

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 and requires improvement for all population groups.

We rated the practice as good for providing safe services because:

  • The practice had systems in place to assess, monitor and manage risks to patient safety.
  • Appropriate recruitment checks were in place for new staff members.
  • Actions had been taken in response to risk assessments.
  • Improvements had been made to the systems for the appropriate and safe use of medicines.
  • There was a system in place for the practice to learn and make improvements when things went wrong.
  • A member of the nursing team had received appropriate training to be the infection prevention and control (IPC) lead. This change had not been reflected in the IPC policy.
  • Staff had received training to recognise sepsis symptoms. However, the poster displayed in the reception area to act as a prompt was not current and relevant.

We rated the practice as good for providing effective services because:

  • New clinical guidance was shared with clinicians and discussed at the monthly practice clinical meetings.
  • Care plans had been introduced for patients who required one. Patients received a copy of the agreed care plan.
  • A system had been put in place to monitor unplanned admissions that ensured patients received a telephone call and a review following discharge.
  • A system was in place to review the consultations and prescribing of the clinical staff, including locums and non-medical prescribers.

We rated the practice as requires improvement for providing caring services because:

  • Patient satisfaction in the National GP Patient Survey had decreased from previous year’s results.
  • An action plan had been put in place to improve patient satisfaction. However, it was too soon to assess the impact this had for patients.

We rated the practice as requires improvement for providing responsive services because:

  • There remained dissatisfaction from some patients regarding access to care and treatment in a timely way.
  • An action plan had been put in place to improve patient satisfaction. However, it was too soon to assess the impact this had for patients.

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

  • Improvements had been made to the leadership and governance of the practice. A business manager had oversight of all management processes.
  • The practice had a vision, set of values and strategy in place.
  • Risk assessments had been completed and analysis of significant events and complaints. Action plans were in place to address areas for change and to improve patient satisfaction.

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

  • Update the infection prevention and control (IPC) policy to reflect the current lead for IPC within the practice.
  • Provide information for reception staff to recognise sepsis symptoms that is current and relevant.
  • Review how they can demonstrate quality improvement. For example, by the use of two cycle audits.
  • Continue to improve and monitor patient satisfaction.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

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

27 February 2020

During a routine inspection

We carried out an announced comprehensive inspection at The Village Medical Centre on 27 February 2020. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, as part of our inspection programme.

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 inadequate overall and requires improvement for all population groups.

We rated the practice as inadequate for providing safe services because:

  • There were gaps in systems to assess, monitor and manage risks to patient safety.
  • Staff did not have the information they needed to deliver safe care and treatment.
  • The practice did not have systems for the appropriate and safe use of medicines.
  • The practice did not have a system to learn and make improvements when things went wrong.

We rated the practice as requires improvement for providing effective services because:

  • There were no processes in place to cascade new clinical guidance such as The National Institute for Health and Care Excellence (NICE) guidelines.
  • Care was not delivered and reviewed in a coordinated way. There were no formal care plans in place for patients.
  • There was no monitoring of unplanned admissions and no risk stratification in place to prevent readmissions.
  • There were no clinical oversight procedures in place to review the consultations and prescribing of the clinical staff including locums and non-medical prescribers.

We rated the practice as good for providing caring services because:

  • Staff dealt with patients with kindness and respect.
  • Feedback from patients was positive regarding the care they received.
  • The practice had identified 86 patients as carers which equated to 1% of the practice population. Support information was available for carers.

We rated the practice as requires improvement for providing responsive services because:

  • People were not able to access care and treatment in a timely way.

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

  • There were flaws in the leadership and governance of the practice.
  • The practice did not have a clear vision, values and strategy.
  • The practice did not have clear and effective processes for managing risks, issues and performance.

The areas where the provider must make improvements are:

  • 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.

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

The areas where the provider should make improvements are:

  • Complete an infection prevention and control audit to reflect the current provider practice.
  • Implement processes to keep clinicians up to date with current evidence-based practice.
  • Continue to identify and support carers.
  • Continue to establish the Patient Participation Group.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

We are mindful of the impact of COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service as required to keep people safe and to hold the provider to account where it is necessary for us to do so.

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