5 September 2022
During an inspection looking at part of the service
We carried out an announced focused inspection at Church Lane - Khan on 5 September 2022. Overall, the practice is rated as requires improvement.
The ratings for each key question are as follows:
Safe - requires improvement
Effective - requires improvement
Caring – good (rating carried over from previous inspection, May 2021)
Responsive – good (rating carried over from previous inspection, May 2021)
Well-led - requires improvement
Following our previous inspection on 11 May 2021, the practice was rated requires improvement overall and for the safe, effective and well-led key questions. The practice was rated good for the caring and responsive key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Church Lane - Khan on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this focussed inspection to follow up on breaches of regulation from a previous inspection.
The focus of the inspection included:
- Safe, Effective and Well-Led key questions
- Any breaches of regulations or ‘shoulds’ identified in the previous inspection
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- 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 found that:
- The last 12 months had been a challenging time for the practice. In addition to the COVID-19 pandemic, the practice had several months without a practice manager, practice nurse and had a shortage of doctors. Many of the vacancies had now been filled and the practice was in a better position going forward to provide a high-quality service.
- The practice premises were in need of some refurbishment, this was currently on hold while the practice was working through future options for the premises.
- We found systems and processes for keeping patients safe were being reviewed following the appointment of the new practice manager. Some of the systems had recently been re-established after gaps in leadership and had yet to fully demonstrate their full effectiveness. For example, safeguarding arrangements, reporting and learning from incidents.
- Our review of clinical records found medicines were generally well managed, with the exception of some older safety alerts, which needed to be addressed.
- Patients received effective care and treatment that met their needs. Our review of clinical records demonstrated patients were receiving appropriate care and treatment. We saw some improvement in childhood immunisations and cervical screening uptake data although further work was required to ensure all indicators reached minimum standards.
- While the practice’s required staff training was well completed, the practice was not always able to demonstrate how it ensured the competence of all staff with extended or advanced roles.
- The practice was not able to demonstrate that it was proactive in ensuring patients wishes were recorded in relation to end of life care.
- Feedback from patients through the National GP Patient Survey and patients we spoke with showed patients were mostly happy with their experience of the service and access to care and treatment.
- The practice had considered and put in place plans to continue to improve the practice and now had the leadership to support this.
- While the practice had addressed some of the governance issues raised at our previous inspection, many of the systems and processes had been put in place relatively recently and needed embedding.
We found a breach 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.
Whilst we found no breaches of regulations, the provider should:
- Put in place arrangements for timely completion for summarising new patient notes.
- Update the fire risk policy so that it is practice specific and complete relevant risk assessments for patients who may not be able to evacuate the premises unaided in the event of a fire.
- Continue to strengthen governance arrangements, in particular around learning from incidents, quality improvement and establishing a freedom to speak up guardian.
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