Ashchurch Medical Centre

We carried out an announced focused inspection at Ashchurch Medical Centre, with the remote clinical interview on 19 October 2021 and site visit on 20 October 2021. Overall, the practice is rated as good.

Safe - Good

Effective - Good

Caring – Not rated

Responsive – Not rated

Well-led – Requires improvement

Following our previous inspection on 10 October 2018, the practice was rated Requires Improvement overall and specifically for the key questions whether the practice was providing safe, effective and well-led care. We rated the practice as good for providing caring and responsive services. We carried out a remote access focused inspection on 26 October 2020 where we looked at the safe and well-led key questions, which was not rated.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Ashchurch Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection to follow up on whether:

• Care and treatment was being provided in a safe way to patients.
• There were effective systems and processes in place to ensure good governance in accordance with the fundamental standards of care.
• There were sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the fundamental standards of care.

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 Good overall.

We have rated this practice as good for providing safe services because:

• The practice had made improvements to the process for managing and auditing two week wait referrals.
• There was a protocol to manage and monitor blank prescriptions.
• The premises were well managed and there were effective systems for managing staff and training records.
• Emergency medicines on site were organised, in date and effectively managed.

We have rated this practice as good for providing effective services because:

• The practice demonstrated a commitment to improving management and monitoring of patients with long-term conditions.
• The practice had worked towards providing effective care for patients during the Covid-19 pandemic.
• The practice’s uptake for cervical screening remained markedly lower than the 80% coverage target for the national screening programme. The practice had also not met the 80% uptake for four of the childhood immunisation uptake indicators and had not met the 90% uptake for one of the indicators, or the WHO based national target of 95%. We did not see sufficient evidence by the practice to understand this low uptake, although the practice had started to put in place systems to address barriers to the uptake of screening and had seen an improvement in the uptake of childhood immunisations in information captured in January 2021. Please see requirement notice below.

We have rated this practice as requires improvement for providing well-led services because:

• The practice had a governance framework, however it was not always effectively managing risks. These included the risks associated with prescribing medicines that required ongoing monitoring and reviewing patients prescribed repeat or multiple medicines in line with guidelines.
• The practice was not always keeping comprehensive clinical records.
• The practice was not always appropriately managing patients with long-term conditions.
• We received feedback from the Patient Participation Group that the practice was open, sympathetic, helpful and had made its best efforts for patients during the difficult circumstances of the Covid-19 pandemic.
• The practice engaged with patients, staff and external partners to improve and develop its services.
• Staff spoke positively about their employment at the practice and felt supported.

We found breaches of regulations. The practice must:

• 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).

In addition to the above, the practice should:

• Continue to review and monitor patients with long-term conditions, including chronic kidney disease and asthma.
• Monitor and ensure appropriate reviews of patients to prevent the development of long term conditions, such as chronic kidney disease.
• Ensure that Medicines and Healthcare products Regulatory Agency (MHRA) alerts are monitored and actioned in a timely manner to protect patient safety.
• Continue to review and monitor practice policies.
• Complete the outstanding actions identified in the fire and health and safety risk assessments.

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