Poplar House Surgery

We carried out an announced inspection at Poplar House Surgery on 20th April 2022. Overall the practice is rated as Good.

The key question ratings are as follows:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

This is the first time this practice has been inspected under its current CQC registration.

Why we carried out this inspection

This inspection was a comprehensive inspection to check the provider was complying with the regulations under the Health and Social Care Act 2008. We inspected all five key questions to determine if the service is safe, effective, caring, responsive and well led.

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Lancashire and South Cumbria. To understand the experience of GP Providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

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 remotely using video conferencing
• Speaking with the PPG chair remotely via the telephone
• 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 shorter site visit
• Further communications for clarification

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

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm, however some staff had not completed the appropriate safeguarding training for their role.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• 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.
• The way the practice was led and managed promoted the delivery of personalised care and support.
• The practice had identified areas for improvement and produced business development and recovery plans to ensure continuous improvement.

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

• Review the coding of patients with chronic kidney disease and ensure the management of patients on high-risk drugs is being completed in accordance with recommended best practice guidelines.
• Continue to support staff to complete outstanding training as identified on practice training records.
• Formalise systems to monitor the prescribing competence of non-medical prescribers.
• A log of significant events and safety alerts should be established to help track progress and actions taken. Ensure all necessary actions are completed on receipt of medicines safety alerts.
• The practice should continue to develop their audit regime.
• The practice should review and put measures in place to improve their breast cancer screening uptake levels.

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