20, 25, 26 September 2023
During a routine inspection
We carried out an announced focused inspection at Rutherford Medical Centre on 20, 25 and 26 September 2023. Overall, the practice is rated as Requires Improvement.
Safe – requires improvement
Effective – requires improvement
Caring – good
Responsive – good
Well-led – good
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Rutherford Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection in line with our inspection priorities.
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:
We rated the provider as Requires Improvement for providing safe services. This was because:
- The arrangements for managing medicines did not always keep patients safe.
- Systems for managing historical safety alerts were not always effective.
- The system in place for recording and acting on historic safety alerts was not effective.
We rated the provider as Requires Improvement for providing effective services. This was because:
- Patients with long-term conditions were not always receiving appropriate monitoring and reviews.
We rated the provider as Good for providing caring services. This was because;
- Staff dealt with patients with kindness and respect.
- Patient feedback about their involvement in decisions about their care and being treated with care and concern was positive.
We rated the provider as Good for providing responsive services. This was because;
- Patients were able to make appointments in a way that met their needs.
- Feedback from patients was being used to drive improvement.
We rated the provider as Good for providing well-led services. This was because:
- There was compassionate, inclusive and effective leadership at all levels.
- The practice had a culture which drove high quality sustainable care.
- The practice involved the public, staff and external partners to sustain high quality and sustainable care.
We found one breach of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
The provider should:
- Improve the uptake of cervical screening for eligible patients.
- Take action to ensure that all Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) assessments are reviewed annually.
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 Health Care