Archived: Pasley Road Health Centre

We carried out an announced inspection at Pasley Road Health Centre on 30 March 2022. Overall, the practice is rated as Good.

Set out the ratings for each key question:

Safe - Good

Effective - Good

Caring - Good

Responsive - Outstanding

Well-led - Good

Why we carried out this inspection

This was a comprehensive inspection as this location had been registered by CQC following a change in service provider.

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 clinical 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 Good overall

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs. There were innovative approaches to providing integrated person-centred care.
• The practice had identified areas where there were gaps in provision locally and had taken steps to address them.
• The culture of the practice and the way it was led and managed drove the delivery and improvement of high-quality, person-centred care.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• There was a strong emphasis on learning and sharing outcomes with the whole team and external organisations to promote best practice.
• All opportunities for learning from internal and external incidents were maximised. All learning was shared with staff regularly.
• Leaders demonstrated they had the capacity and skills to deliver high quality, sustainable care.
• There was effective leadership at all levels which supported innovation, implementation of processes and the continuous monitoring of patient care.
• There was continuous commitment to patients and external stakeholders to share information, ideas and improvements. This included the development of new services and an audit programme to drive quality improvement.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. This included enhanced infection control procedures.
• Effective procedures for the management of medicines were in place to ensure patients received appropriate reviews. This included regular monitoring of patients on high risk medicines.
• There was emphasis on staff wellbeing, and this was demonstrated through discussions with staff and evidence of appraisals. Staff were encouraged to develop and were provided with training opportunities.
• Risk management processes were in place and we found assessments of risks had been completed. These included fire safety, health and safety, and infection control. This ensured that risks had been considered to ensure the safety of staff and patients and to mitigate any future risks.

We found areas of outstanding practice:

• The practice had implemented a range of webinars to promote health awareness. These included COVID-19, child’s health and cervical screening. Patients were sent text messages to advise them of the date of the webinar and a chat function was installed so patients could ask questions. Due to the popularity of the webinars, further ones were introduced and in a range of different languages to support patients who did not have English as a first language.
• The practice group clinical psychologist had implemented an outreach programme for high schools to improve awareness around mental health and provide educational support on key topics such as low mood, anxiety and self-harm. This had provided support to both students and teachers.
• During the COVID-19 vaccination campaign, the practice used the 15 minute observation period after the vaccine had been administered to do a point of care review of patients with long term conditions. This included blood samples and blood pressure checks .
• To support patients from ethnic minority backgrounds that were not registered with a GP practice, a mobile phone number was set up with staff who could speak a range of languages. A video promoting the service was also produced.
• The practice group had worked with the CCG to implement a population health management tool to identify patients in at risk groups. The care planning strategy implemented by the practice group and led by the PCN consultant geriatrician used a multi-disciplinary approach to provide a training programme and ensure regular reviews of care plans were completed. The practice had reduced hospital length of stay for patients with complex needs by 25% since the implementation of this strategy and across the practice group a 40% reduction had been seen.

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

• Continue to encourage patients to attend childhood immunisations and cervical screening appointments.
• Improve recruitment processes and review practice recruitment policy to maintain effective procedures for the employment of staff.

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