Circle GP Surgery Also known as Dr Idress Said Kamal

We carried out a comprehensive inspection at Green Wrythe Surgery on 19 May 2022 and a remote clinical review on 16 May 2022 as part of our inspection programme. Overall, the practice is rated as Requires Improvement.

Safe – Requires Improvement

Effective – Requires Improvement

Caring – Good

Responsive – Good

Well-led – Requires Improvement

Following our previous inspection on 26 April 2017 (under their previous provider registration), the practice was rated as Good overall with requires improvement in responsive for issues in relation to access to appointments and getting through the surgery by phone.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Green Wrythe Surgery 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 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:

• Staff had not completed safeguarding training relevant to their role.
• Recruitment checks were not carried out in accordance to practice policies and staff immunisation records were not maintained according to guidance.
• Infection control issues were not identified and addressed in a timely manner.
• The practice did not have effective systems in place for the safe management of medicines.
• Patients with long-term conditions were not consistently reviewed and monitored.
• The national GP Patient survey indicators in relation to way the staff treated people was below average.
• 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.
• Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care. However, governance arrangements in place and the processes for identifying, managing and mitigating risks were not effective.

We have rated this practice as Requires Improvement overall and Requires Improvement in Safe, Effective and Well-led.

We found two breaches of regulations. The provider must:

• Ensure that care and treatment is provided in a safe way for patients.
• Establish effective systems and processes to ensure good governance in accordance with fundamental standards of care.

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

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

• Improve uptake for childhood immunisations and cervical screening.
• Improve low scoring areas of the national GP patient survey.
• Re-establish a Patient Participation Group.

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