Godiva Group Practice Also known as Clay Lane Health Centre

We carried out an announced inspection at Godiva Group Practice on 4 May 2022. Overall, the practice is rated as Requires improvement.

The ratings for each key question:

Safe – Requires improvement.

Effective – Requires improvement.

Caring - Good.

Responsive - Good.

Well-led – Good.

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 Requires improvement overall

We found that:

• The practice had a backlog of medicine reviews for patients prescribed certain high risk medicines and patients prescribed medicines to treat specific long term conditions. Although the practice had identified the issues and had a plan in place, plans were ongoing and we found there were still many patients who required a review. Actions were in their infancy and were yet to be embedded.
• Childhood immunisation and cervical screening uptake was below national expected levels. Uptake rates had declined since the last CQC inspection. Although the practice had identified the issues and had a plan in place, this was still in the process of being implemented and data showed lower rates than expected.

However,

• Patients mainly received effective care and treatment that met their needs.
• We observed staff dealt with patients with kindness and respect.
• 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.
• There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.
• The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care. The provider were aware of areas which required strengthening; such as medicines management and actions were ongoing.
• The practice team demonstrated a commitment to learning and improvement at all levels of the organisation.
• Clinical staff received regular updates and training and took steps to ensure they were familiar with the most recent clinical guidelines.
• There was a programme of quality improvement, including clinical audit.

We found breaches of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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