Archived: Wellesley Road Practice

We carried out an announced inspection at Wellesley Road Practice on 29 June 2022. Overall, the practice is rated as Requires Improvement.

Set out the ratings for each key question

Safe - Requires improvement

Effective - Requires improvement

Caring - Good

Responsive - Good

Well-led - Requires improvement

Why we carried out this inspection

This was a comprehensive inspection. This was a new registration and we carried out this inspection as part of our regulatory functions.

At this inspection we covered all key questions:

• Are services safe?
• Are services effective?
• Are services caring?
• Are services responsive?
• Are services well-led?

How we carried out the inspection

Throughout the pandemic, CQC has continued to regulate and respond to risk. At this inspection, we visited the practice which included:

• Conducting staff interviews.
• 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.

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.
• Patient Group Directions (PGDs) were not signed by all the practice nurses.
• The practice’s uptake of the national screening programme for cervical and breast cancer screening was below the national average.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The Patient Participation Group (PPG) was active.
• The practice carried out repeated clinical audits.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.

We have rated this practice as Requires Improvement overall.

We found:

There was a lack of good governance in some areas.

• Safeguarding children and safeguarding vulnerable adults registers were not maintained or reviewed on a regular basis. Most of the cases were reviewed on an ad-hoc basis.
• Recruitment checks including Disclosure and Barring Service (DBS) were not always carried out in accordance with regulations and records were not kept in staff files.
• Risks to patients were not assessed and well managed in relation to health and safety, fire safety, staff vaccination and the management of legionella.
• The practice did not have any formal monitoring system in place to assure themselves that blank prescription forms were recorded correctly, and their use was monitored in line with national guidance.
• Annual appraisals were not carried out in a timely manner.
• Not all patients were able to access the telephone system in a timely manner.
• Our clinical records searches showed that the practice had an effective process for monitoring patients’ health.
• Patient treatment was always regularly reviewed and updated.
• Structured medicines reviews for patients with long term conditions were carried out in a timely manner.
• Feedback from patients was positive about the way staff treated people.

We found three breaches of regulations. The provider must:

• 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.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The provider should:

• Carry out an annual review of significant events.
• Take necessary steps to improve telephone access.
• Include necessary information of the complainant’s right to escalate the complaint to the Ombudsman if they are dissatisfied with the response.
• Take necessary steps to address CQC registration issues.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services