The Care Quality Commission
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Glebedale Medical Practice

Overall: Good read more about inspection ratings

Fenton Health Centre, Glebedale Road, Fenton, Stoke On Trent, Staffordshire, ST4 3AQ (01782) 743121

Provided and run by:
Glebedale Medical Practice

All Inspections

23 November 2022

During a routine inspection

We carried out an announced comprehensive inspection) at Glebedale Medical Practice on 23 November 2022. Overall, the practice is rated as Good.

Safe - Requires improvement

Effective -Good

Caring - Good

Responsive -Good

Well-led – Good

The previous Care Quality Commission inspection on 11 May 2021, the practice was rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Glebedale Medical Practice 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.

  • We inspected, safe, effective, caring, responsive and well led key questions.
  • We followed up on the ‘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.
  • Staff feedback questionnaires
  • Speaking with other stakeholders such as care homes.

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 practice provided care in a way that kept patients safe and protected them from avoidable harm. However, some areas were identified in recruitment processes for improvement.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way. The practice had completed an in-house survey and implemented changes to further improve patient access.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care. The practice had recognised the need and had insight into the need to develop a measurable strategy.

We found a breach of regulations. The provider must:

  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The provider should:

  • Document in full the actions taken by the practice to mitigate risk following a significant event or incident.
  • Strengthen the systems for the validation and reconciliation of the practice safeguard registers with the appropriate local safeguarding social service team.
  • Continue to improve the uptake of cervical screening.
  • Continue to improve the uptake of childhood immunisations.
  • Consider the need to close the branch site doors between 1pm and 2pm with safe staffing levels.
  • Implement the suggestion made for the inclusion of a representative of each staff role at the practice meetings on a rotation basis.
  • Continue with their activity to establish a Patient Participation Group (PPG).
  • Continue with the development of a credible and measurable practice strategy.
  • Engage staff with clear GP leadership and provide staff feedback on suggestions made and actions taken in response to feedback.

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

11 May 2021

During an inspection looking at part of the service

We carried out an announced follow up inspection at Glebedale Medical Practice on 11 May 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

  • Safe - Good
  • Effective -Good
  • Caring – Good
  • Responsive – Good
  • Well-led – Good

Following our previous inspection on 10 January 2020, we rated this practice as good overall and in all key questions except for safe which we rated as requires improvement. We rated all of the population groups as good except for people experiencing poor mental health which we rated as requires improvement.

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

Why we carried out this inspection/review

This follow up inspection was a focused follow-up of information with a site visit to follow up on:

  • Safe domain
  • The breach of regulation and ‘shoulds’ identified in the previous inspection

Ratings were carried forward from the previous inspection which included the effective, caring, responsive and well led domains.

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 inspection 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 on-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 Good overall and good for all population groups.

We found that:

  • The practice had actioned and put measures in place for all the improvements areas identified in the previous inspection, including the breach in regulation.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Of the clinical records sampled we saw that patients experiencing poor mental health had care plans in place and the provider’s electronic coding system was completed to state that they had had a care plan review.

Whilst we found no breaches of regulations, the provider should:

  • Regularly review the changes made to the monitoring of high-risk medicines to ensure these are embedded for good governance.
  • Continue to encourage and improve the uptake of cervical screening and childhood immunisation programmes.
  • Consider the monitoring of the cleaning schedules completed by the contract cleaners.

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

10 Jan 2020

During a routine inspection

We carried out an announced comprehensive inspection at Glebedale Medical Practice on the 10 and 14 January 2020 as part of our inspection programme.

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 good overall and in all key questions except for safe which we rated as requires improvement. We rated all of the population groups as good except for people experiencing poor mental health which we rated as requires improvement.

We rated the practice as requires improvement in safe because:

  • The safeguarding policy had been updated but some key clinical staff were unaware of where to find it.
  • The practice maintained safeguarding lists of vulnerable adults and children but systems for ensuring the accuracy of the lists were not fully effective.
  • All the required risk assessments had not been completed for the branch practice. This included a fire risk assessment and a risk assessment for outstanding actions in response to an unsatisfactory rating for the five-year electrical testing of fixed wires. Cleaning staff did not have access to COSHH risk assessments.
  • There was a process in place to monitor the health of patients prescribed high-risk medicines. However, a patient of child bearing age who was prescribed valproate had not been made fully aware of the need for highly effective contraception.

We rated the practice as good in effective because:

  • Patients received effective care and treatment that met their needs.
  • Multi-disciplinary team meetings were in place to support patients near the end of their life.
  • The practice had clear processes in place to follow up children that did not attend immunisations. However, three of the four childhood immunisation uptake indicators were below the national 90% target.
  • The practice’s cervical screening rate had increased over time following the actions they had taken.
  • Patients experiencing poor mental health did not have care plans in place. Coding had inaccurately been completed to state that they had. Following our inspection, the practice sent us a template they would use to complete care plans for this group of patients.

We rated the practice as good in caring because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice had identified 297 patients as carers within the practice. This represented 2.4% of the practice population.

We rated the practice as good in responsive because:

  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • Complaints were used to improve the quality of the service.

We rated the practice as good in well-led because:

  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Leaders demonstrated that they understood the challenges to quality and sustainability and put effective action plans in place to address them.
  • There was a realistic strategy to achieve their priorities.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Inform and monitor that all staff know where to find the safeguarding policy.
  • Explore ways of improving engagement with community primary care staff to support vulnerable patients and patients with complex needs.
  • Explore further ways of increasing patient uptake of childhood immunisations and cancer screening.
  • Identify ways of reducing the exception reporting for patients experiencing poor mental health.

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

1 December 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We inspected this service on 1 December 2014 as part of our new comprehensive inspection programme.

The overall rating for this practice is good. We found the practice to be good in all areas. We found the practice provided good care to all of their population groups including older people, patients with long term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health, including dementia.

Our key findings were as follows:

  • Patients were kept safe because there were arrangements in place for staff to report and learn from key safety risks. The practice had a system in place for reporting, recording and monitoring significant events over time.
  • People’s needs were assessed and care was planned and delivered in line with current legislation.
  • Patients were generally satisfied with how they were treated and felt that staff treated them with compassion, dignity and respect.
  • The practice had a well-established and well trained team who had expertise and experience in a wide range of health conditions.
  • There was a transparent and inclusive culture at the practice which encouraged contributions from staff and patients in the development of the service.

However, there were also areas of practice where the provider needs to make improvements. The provider should:

  • Review the system for reporting, recording and monitoring significant events to ensure that actions identified for learning or improvement, as a result of the significant event, are completed.
  • Ensure that all nursing staff receive the appropriate level of training around safeguarding children in line with best practice recommendations
  • Review the practice’s safeguarding policy to ensure it is aligned with the Inter-agency Adult Protection Procedures as developed by the local Staffordshire and Stoke-on-Trent Adult Safeguarding Partnership.
  • Review how prescriptions are managed, stored and disposed of, in conjunction with national best practice guidelines.
  • Ensure all areas of risk in relation to health and safety are assessed and monitored.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice