12 March 2019
During a routine inspection
We carried out an announced comprehensive inspection at Malling Health @ Blue Suite on 24 July 2018. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the July 2018 inspection can be found by selecting the ‘all reports’ link for Malling Health @ Blue Suite on our website at www.cqc.org.uk.
After our inspection in July 2018 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 inspection on 18 September 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 24 July 2018. The practice was not rated as a consequence of this inspection.
At our inspection on 18 September we found that the practice had made some progress but had not fully met the Warning Notices issued on 6 August 2018 and we therefore issued requirement notices. The full comprehensive report on the September 2018 inspection can be found by selecting the ‘all reports’ link for Malling Health @ Blue Suite on our website at www.cqc.org.uk.
After the inspection in September 2018 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.
This inspection was undertaken following the period of special measures and was an announced comprehensive inspection carried out on 12 March 2019 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspections on 24 July 2018 and 18 September 2018. This report covers findings in relation to those requirements.
Overall the practice is now rated as Requires Improvement.
The key questions are rated as:
Are services safe? – Good.
Are services effective? – Requires Improvement.
Are services caring? – Requires Improvement.
Are services responsive? – Requires Improvement.
Are services well-led? – Good.
At this inspection we found:
- The practice had continued to make improvements to the systems, processes and practices that helped to keep patients safe and safeguarded from abuse. These were now effective.
- The practice had continued to revise and improve their assessment and management of risks to patients, staff and visitors. These were now effective.
- There had been further improvements to the arrangements for medicines management in the practice and patients were now being kept safe as a result.
- The practice was able to demonstrate that they learned from and made improvements when things went wrong.
- The practice had action plans to improve quality and performance and was still in the process of implementing, embedding and reviewing their effectiveness.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients were able to access care and treatment from the practice within an acceptable timescale for their needs.
- Improvements had been made to help ensure that multidisciplinary team meetings were being held and were effective.
- Improvements to the practice’s complaints system had taken place. It was now being operated effectively and had been made accessible to all patients.
- Governance arrangements had been improved and were being effective.
- There had been improvements to the practice’s systems and processes for learning, continuous improvement and innovation which were now effective.
The areas where the provider must make improvements as they are in breach of regulations are:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas where the provider should make improvements:
- Continue to implement improvements to the practice’s computer system in relation to children on the at risk register.
- Continue to implement and evaluate planned activities to improve patient satisfaction scores.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.
Rosie Benneyworth
Chief Inspector of Primary Medical Services and Integrated Care