We carried out an announced comprehensive inspection at Kingfisher Berkley Practice on 15 December 2022. Overall, the practice is rated as Good.
We rated each key question as follows:
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Why we carried out this inspection
We carried out an announced comprehensive inspection at Kingfisher Berkley Practice as part of our inspection programme and to provide a rating for the service, as it had not been inspected before.
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.
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:
- There were effective systems and processes in place for recruitment and infection prevention and control.
- The practice had implemented systems that mostly supported the appropriate and safe use of medicines, this included regular monitoring arrangements for patients on high risk medicines. The practice did not however, have a policy or protocol in place to manage patients who did not respond to requests for monitoring to ensure consistency.
- Practices and processes were in place to keep people safe and safeguarded from abuse. However, the records of children and adults in the same household with safeguarding concerns were not always cross referenced.
- There was a structured and coordinated approach to the management of patients with long term conditions.
- The practice had met the minimum 90% uptake target for all five childhood immunisation indicators.
- The practice was below the minimum requirements for the uptake of cervical cancer screening and taking action to improve.
- Staff were provided opportunities for training and development with access to appraisals and supervision.
- Staff dealt with patients with kindness and respect. There was positive patient feedback. The national GP survey results showed the practice was mostly above the local and national averages for questions relating to caring.
- Feedback from the national GP survey showed patients responded positively to questions relating to access including flexibility and choice.
- The practice was responsive to the needs of vulnerable people including those who are homeless.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
- There was compassionate, inclusive and effective leadership at all levels. Leaders continued to develop capacity and skills with a commitment to delivering high quality, sustainable care.
- There was clear and effective accountability and oversight to support good governance.
Whilst we found no breaches of regulations, the provider should:
- Develop a structured process to manage patients who do not respond to requests for high risk medicine monitoring to ensure consistency. Implement this process and continue to follow up all patients who have not responded.
- Implement effective systems to monitor and review information documented in patients records on an ongoing basis. This includes patients who do not respond to requests for reviews and cross-referencing of records of children and adults in the same household with safeguarding concerns
- Continue to monitor and take action to improve the uptake of cervical cancer screening.
- Continue to review prescribing rates of medicines prescribed to patients for mental health needs to ensure optimal use of the medicine aligned with patient’s health needs.
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