Ridgeway View Family Practice

We carried out an announced inspection at Ridgeway View Family Practice on the 11-13 July 2022. Overall, the practice is rated as requires improvement.

Safe - Requires improvement

Effective - Requires improvement

Well-led - Requires improvement

Following our previous inspection on 11 December 2022 the practice was rated Good overall and for all key questions.The full reports for Ridgeway View family Practice previous inspections can be found by selecting the ‘all reports’ link for on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection to follow up on information received about the service.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering 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 facilities.
• Speaking with staff during the visit to the practice.
• 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 staff questionnaire.
• A site visits.

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.
• information from the provider, patients, the public and other organisations.

We have rated this practice as Requires Improvement

We found that:

• The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse. Staff had information they needed to deliver safe care and treatment.
• Staff worked together and with other organisations to deliver effective care and treatment.
• Adequate staffing levels had not yet been achieved and recruitment was ongoing. The practice was able to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
• Appropriate standards of cleanliness and hygiene were met but auditing to ensure consistent compliance was not maintained.
• The practice learned and made improvements when things went wrong. However, there was a lack of auditable record, including root cause analysis or record to demonstrate any learning as a result and any changes in practice.
• The practice had systems for the appropriate and safe use of medicines. However, there was a lack of consistent process for monitoring patients’ health in relation to the use of medicines including some high-risk medicines and medicine alerts. Ongoing monitoring was being maintained but there was a backlog of medicine reviews. Actions were being taken to follow up late medicine reviews.
• Staff were consistent and proactive in helping patients to live healthier lives. However, patients’ needs were not always assessed, and care and treatment were not consistently delivered in line with current legislation, standards and evidence-based guidance. There was limited monitoring of the outcomes of care and treatment.
• The practice always obtained consent to care and treatment in line with legislation and guidance.
• People were able to access care and treatment in a timely way.
• There was effective leadership at all levels. The practice had a vision to provide high quality sustainable care and had a culture which drove that care. Communication of changes had impacted on staff culture.
• The overall governance arrangements were not fully embedded to enable a clear overview of the service. The practice did not have consistently clear and effective processes for managing risks, issues and performance.
• There was a demonstrated commitment to using data and information proactively to drive and support decision making
• The practice involved the public, staff and external partners to sustain high quality and sustainable care. There were systems and processes for learning, continuous improvement and innovation.

We found two breaches 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.

The provider should:

• Continue to monitor the action response times for pathology results.
• Continue with the programme of coverage of women eligible to be screened for cervical cancer.
• Consider the inclusion of staff in the development of the practices vision and values.
• Review the storage of oxygen cylinders to ensure they were stored securely.

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