19 October 2021
During an inspection looking at part of the service
We carried out an announced focussed inspection at Iwade Health Centre on 9 October 2020. The practice was not rated as a consequence of this inspection. The full comprehensive report on the October 2020 inspection can be found by selecting the ‘all reports’ link for Iwade Health Centre on our website at www.cqc.org.uk.
After our inspection in October 2020 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.
We carried out an announced focussed follow-up review on 25 May 2021 to assess the provider’s compliance to meet the legal requirements against the warning notices issued in relation to breaches in regulations that we identified at our previous inspection in October 2020. The practice was not rated as a consequence of this review. The full report on the May 2021 review can be found by selecting the ‘all reports’ link for Iwade Health Centre on our website at www.cqc.org.uk.
After our review in May 2021 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.
Why we carried out this review:
We carried out an announced focussed follow-up inspection on 19 October 2021 (at short notice) to assess the provider’s compliance to meet the legal requirements against the requirement notice issued in relation to the breaches in regulations that we identified in our previous review in May 2021. This report covers findings in relation to those requirements.
How we carried out the 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 in line with all data protection and information governance requirements.
This included:
- Requesting evidence from the provider.
- A short site visit.
Our judgement of the quality of care at this service is based on a combination of what we found when we carried out the review, information from our ongoing monitoring of data about services and information from the provider, patients, the public and other organisations.
This practice was not rated as a consequence of this inspection.
At this inspection we found:
- Risk assessments failed to contain sufficient rationale for the lack of hepatitis B vaccination records for one member of clinical staff.
- The practice’s induction system for temporary staff had not been updated in a timely manner and not all staff were up to date with basic life support training.
- The practice’s reception had been closed to staff since June 2021 which was not in line with NHS England standard operating procedures.
- Improvements had not been sufficiently effective and were still required to ensure that all staff followed best practice guidance when carrying out reviews of patients diagnosed with chronic obstructive pulmonary disease (COPD).
- Requirements of some staff to provide practice clinical leadership (or clinical supervision) in the absence of the clinical lead salaried GP were not included in their written job descriptions.
- Improvements to the management of some current and future performance were not yet sufficiently effective and other risk management improvements were required.
The areas where the provider must make improvements are:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care