The Care Quality Commission
  • Doctor
  • GP practice

Archived: Garston Family Health Centre

Overall: Good read more about inspection ratings

32 Church Road, Garston, Liverpool, Merseyside, L19 2LW

Provided and run by:
Dr Don Jude Mahadanaarachchi

Important: The provider of this service changed. See new profile
Important: The provider of this service changed. See old profile

All Inspections

28 29 June 2021

During an inspection looking at part of the service

We carried out an announced remote assessment at Garston Family Health Centre on 28 and 29 June 2021. This review focused on the regulatory breaches previously found.

This review did not result in the provider being awarded a rating as a site visit was not undertaken.

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

Why we carried out this review.

This review was a focused follow-up remote review of information without undertaking a site visit to follow up on 28 and 29 June 2021.

We looked at the following key questions:-

Safe

Effective

Responsive

Well-led

This review was a focused follow-up review of information without undertaking a site visit, to follow up on two breaches of regulation. These were identified at the previous review we carried out between 9 and 12 November 2020. At that time, we identified improvements were need to the governance of the service and to ensure medicines were managed safely. We issued warning notices for breaches of:

  • Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
  • Regulation 17 HSCA (RA) Regulations 2014 Good governance

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

How we carried out the review

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 reviews differently.

This review was carried out in a way which enabled us to not spend any 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

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 found that a number of improvements had been made since the last remote assessment, including:

  • The provider had undertaken a recruitment drive and new systems and induction programmes were developed to support new and temporary staff.
  • The processes for monitoring patients’ health in relation to the use of medicines including high risk medicines, had significantly improved.
  • There had been improvements to policies and procedures to ensure there was clear guidance for staff.
  • The arrangements for identifying, recording and managing risks, issues and mitigating actions had improved. This included the management of significant events and complaints monitoring.
  • The practice had systems and processes to keep clinicians up to date with current evidence-based practice.
  • The practice had an improved programme of quality improvement and used information about care and treatment to make improvements.
  • We found that improvements had been made to the governance systems to ensure better oversight, monitoring and review.
  • There was improved clinical leadership from a lead GP and nurse and regular monthly clinical meetings with practice staff.
  • Staff reported that they felt able to raise concerns without fear of retribution.
  • Staff reported that there had been improvements to communication and their involvement in the operation of the service.

We found areas where improvements needed to be made:-

  • Since the last inspection the provider had developed a training plan. However, there were gaps identified in the required mandatory training for a number of clinical staff.
  • A systematic approach to determine the number of staff and range of skills required in order to meet the needs of patients and keep them safe was not in place.
  • There was insufficient support or monitoring of clinical staff. Appraisals and formal supervision were not taking place.
  • The provider used locum staff to maintain clinical staffing levels without effective oversight.

We found a breach of regulations. The provider must:

  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

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

The areas where the provider should make improvements:

  • Review and improve significant event reporting and analysis forms to fully document learning and action taken.
  • Review and improve processes to seek feedback from patients about access to the services provided.
  • Review and improve the procedures for offering patients a service at another location operated by the provider.
  • Review and improve the policy for staff development and retention.
  • Review and improve the record keeping of checks to ensure the receptionists are allocating patients to the correct area of the triage system.
  • A programme for audits should be put in place which reflects local, national and service priorities.
  • The provider should ensure that a written agreement or contract is in place for GP locums working at the practice. Formal procedures and monitoring processes should be put into place to ensure safe treatment and care is carried out.

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

09/11/2020 - 12/11/2020

During an inspection looking at part of the service

This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk in light of the Covid-19 pandemic and reducing the burden placed on practices by minimising the time inspection teams spend on site.

This was conducted with the consent of the provider. Unless the report says otherwise, we obtained the information in it without visiting the Provider. The assessment did not include on-site inspection and therefore the practice has not been rated or ratings from our previous inspection have not been reviewed.

Background:

We undertook a remote regulatory assessment between 9 and 12 November 2020 following information of concern being brought to our attention. The concerns related to staffing levels, care and treatment of patients, the management of the service and staff welfare. The practice had previously not been inspected under this provider’s registration.

The service is registered with CQC under the Health and Social Care Act 2008 to provide the regulated activities of: Diagnostic and screening procedures, Maternity and midwifery services and Treatment of disease, disorder or injury.

The registered provider is the responsible individual and is the ‘registered person’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During the assessment we reviewed Garston Family Health Centre’s clinical record system which included the practice’s task management system and a sample of electronic patient records.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we carried out the assessment.
  • information from our ongoing monitoring of data about services and
  • information from the provider, staff, patients, the public and other organisations.

We found that:

  • Staff felt patients had their needs met and that overall care was prioritised depending on need. However, the workload was high, sometimes excessive and sometimes there were insufficient staff to meet patient demand.
  • The provider did not have a system in place to effectively assess and manage staffing needs to ensure patient safety.
  • There were gaps in systems to assess, monitor and manage risks to patients, for example, the management of patients’ medicine reviews.
  • The monitoring of patients’ medication, including high risk medication, was not robust. Medication reviews and monitoring was not done in a timely manner, lacked oversight and was not always managed safely.
  • There were no assurance processes that patients test results were processed and acted upon in a timely manner.
  • The systems to report, analyse, learn and make improvements when things went wrong were not robust. The significant event and complaint procedures and processes needed improvement.
  • Good governance systems and processes were not in place or were not being operated effectively. The governance framework was not clearly defined or identified. There was insufficient review, analysis and a lack of action planning and review.
  • There was a senior management team and structure in place, they had a vision and supporting strategies in place.
  • The organisation and the practice were supported by a culture strategy and staff reported that they felt able to raise concerns without fear of retribution. Staff generally felt well supported by colleagues and managers and they felt the culture of the practice was one of openness and honesty.
  • There were a number of communication methods in place, however improvements were needed. Structured, documented meetings that looked specifically at operational or clinical issues were not taking place at practice level.
  • Some of the policies and procedures that we looked at required review and improvements as they lacked significant detail, such as the checks to be undertaken during the staff recruitment process.
  • The system in place for monitoring and auditing the practice required improvement. The audit plan did not demonstrate that it was based on local, national or service priorities.
  • Improvements were needed to the support provided to clinical staff. There were informal arrangements to review the consultations, referrals and prescribing of clinicians and no formal induction for locum staff. Locum staff were not always included in the appraisal process, audits or involved in the significant event process.

The areas where the provider must make improvements:

  • 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.

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

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care