Yellow Practice

Updated 12 September 2022

Yellow Practice is located in Walton on Thames and offers general medical services to approximately 4,300 patients. The service is provided from the following location:

Yellow Practice, The Health Centre, Rodney Road, Walton-on-Thames, KT12 3LB

The premises are owned by a third-party organisation who are responsible for the maintenance of the building. The building is shared with two other GP practices and a number of other health services.

The practice has a higher than average number of patients over 65 years when compared to the England average.

Information published by Public Health England shows that deprivation within the practice population group is rated nine out of 10. The lower the decile, the more deprived the practice population is relative to others. (Deprivation covers a broad range of issues and refers to unmet needs caused by a lack of resources of all kinds, not just financial).

According to the latest available data, the ethnic make-up of the practice area is 90% White, 5% Asian, 3% Mixed, 1% Black and 1% Other.

The practice is a teaching practice; at the time of our inspection there were no students attached to the practice. (Teaching practices take medical students and training practices have GP trainees and F2 doctors who are qualified doctors but have not yet completed specialist training as a GP).

The practice is open between 8am and 6.30pm Monday to Friday. Extended hours appointments are offered from 7.30am to 8am on Wednesday mornings. When the practice is closed patients are advised to call NHS 111 where they will be given advice or directed to the most appropriate service for their medical needs.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with national guidance, most GP appointments are initially telephone consultations. Patients are assessed over the telephone to determine if the GP needs to see the patient face-to-face.

The practice is part of a federation of GP practices that offers evening appointments until 9pm and weekend appointments from 9am until 12pm. These appointments are run from locations in Walton-on-Thames, Chertsey, Ashford, Sunbury-on-Thames and Woking.

For further details about the practice please see the practice website: www.yellowpracticewalton.nhs.uk

The practice is registered with CQC to provide the following regulated activities;

Diagnostic and screening procedures,

Treatment of disease, disorder or injury,

Maternity and midwifery services

Family planning services.

Updated 12 September 2022

We carried out an announced inspection at Yellow Practice from 27 – 30 June 2022. Overall, the practice is rated as Requires Improvement

Set out the ratings for each key question

Safe - Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led - Requires Improvement

Following our previous inspection in October 2021 the practice was rated Requires Improvement overall and for the key questions Safe and Effective, Well Led was rated as inadequate and Caring and Responsive as Good.

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

Why we carried out this inspection

The practice had been previously rated as Requires Improvement in October 2021. This inspection was to follow up breaches of regulations 12, 15 and 17as identified in our previous inspection.

How we carried out the inspection/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 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 dealt with patients with kindness and respect and involved them in decisions about their care.
• Staff told us they felt well supported and that leaders were approachable.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• The staff recruitment file for a recently recruited staff member for the nursing team, did not contain all of the required information to ensure safe recruitment.
• Staff training was up to date, which included safeguarding, basic life support, infection prevention and control, and sepsis.
• We saw evidence that staff members took part in team meetings to share learning from safety alerts, complaints and significant events.
• The remote searches of the clinical system carried out by the CQC GP specialist advisor indicated that systems were working as intended.
• Actions from risk assessments were recorded and where possible completed in a timely manner. However, there was a delay in actions required by the landlord and the external cleaning company.
• New infection control audits had taken place and actions were clearly recorded. However, the provider had not recognised an infection control risk to their patients and staff members when using a shared room with the other two practices within the building.
• Emergency equipment we reviewed contained out of date oxygen masks for both children and adults.
• Staff had the required immunisations. However, the policy lacked consistency when referring to the title of roles within the practice.

We found breaches of regulations. The provider must:

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

The provider should:

• Review the immunisation policy in relation to the varying titles for roles within the practice and ensure consistency.

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