Hednesford Medical Practice

We carried out an announced inspection at Hednesford Medical Practice on 20 September 2021. Overall, the practice is rated as Good.

The ratings for each key question are as follows:

Safe - Good

Effective – Good

Caring - Good

Responsive – Requires Improvement

Well-led – Good

Why we carried out this inspection

This comprehensive inspection was carried out following changes to registration and legal entity as a result of the mergers of two practices, Hednesford Medical Practice and Dr Murugan and Partner Surgery in July 2020. The change resulted in Hednesford Medical Practice changing from a sole provider GP service to a partnership GP service. This was the practice’s first inspection as a partnership following the merger.

At our previous inspection of Hednesford Medical Practice on 5 February 2020, the practice was rated Good overall and for all key questions.

At our previous inspection of Dr Manickam Murugan’s surgery on 12 March 2019, the practice was rated Requires Improvement overall.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Hednesford Medical Practice and Dr Manickam Murugan’s surgery on our website at www.cqc.org.uk

How we carried out the inspection

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 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 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 Requires Improvement for providing responsive services and Requires Improvement for all population groups. This was because of the concerns raised regarding timely access to the service and the lower than average National Patient survey satisfaction results. This affected all population groups.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm. Patient records clearly detailed how the practice had responded to safeguarding concerns.
• 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. The practice had identified a high percentage of the patient population as carers.
• The practice adjusted how it delivered services during the COVID-19 pandemic, however the National Patient Survey Results for 2021 were below local and national averages. The practice had produced an action plan in response to this and advised an in-house survey would be undertaken in November 2021.
• The way the practice was led and managed promoted the delivery of high-quality, person-centred care. Staff reported they were well supported in their work despite the challenging times, significant staff changes, merger of the two practices and changes in partnership.

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

• Ensure all recruitment checks are undertaken
• Address all outstanding training for staff.
• Further explore and implement strategies to increase the update of cervical cancer screening and childhood immunisations.
• Review the security of the vaccine fridge and improve monitoring of the fridge temperature checks.
• Respond to patient feedback to improve patient satisfaction in relation to access.

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