The Care Quality Commission
  • Doctor
  • GP practice

The Glebe Family Practice

Overall: Requires improvement read more about inspection ratings

Vicarage Road, Gillingham, Kent, ME7 5UA (01634) 576347

Provided and run by:
The Glebe Family Practice

All Inspections

08 September 2022

During a routine inspection

We carried out an announced comprehensive inspection at The Glebe Family Practice on 8 September 2022. Overall, the practice is rated as Requires Improvement.

The key questions are rated as:

Safe – Requires Improvement

Effective – Requires Improvement

Caring – Good

Responsive - Good

Well-led – Requires Improvement

Following our previous inspection on 17 September 2015, the practice was rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Glebe Family Practice on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

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 have rated this practice as Requires Improvement for providing safe services because:

  • Some improvements were needed to the systems and processes designed to keep people safe.
  • The practice’s systems for the appropriate and safe use of medicines required improvement.
  • The practice’s systems and processes did not allow the practice to effectively act on safety alerts.

We have rated this practice as Requires Improvement for providing effective services because:

  • Improvements were needed to the practice’s system for monitoring patients with long term conditions.

We have rated this practice as Requires Improvement for providing well-led services because:

  • The practice’s processes did not always effectively manage risks, issues and performance

We found that:

  • Patients did not always receive effective care and treatment that met their needs.
  • There was a comprehensive programme of quality improvement activity.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • Information about staff vaccination was not held in line with current guidance.
  • There was not an effective process for monitoring security of blank prescription pads.
  • The system for receiving, sharing and acting on safety alerts did not always keep people safe.
  • Improvements were needed to the processes for monitoring patients with long term conditions.

We found one breach of regulation. The provider must:

  • 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 are:

  • Implement a process that identifies the frequency at which Disclosure and Barring Service (DBS) checks for staff should be completed.
  • Store and monitor vaccines in line with UKHSA guidance, ensuring the practice’s cold chain policy is implemented correctly.
  • Hold and record regular staff and clinical governance meetings.

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

17 August 2015

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at he Glebe Family Practice on the 17 August 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe and well-led services.

Our key findings across all the areas we inspected were as follows:

  • The practice had systems to ensure that patients’ records were held in a secure way and accessible to authorised staff only.
  • Safeguarding policies had been updated to include contact details of relevant child safeguarding bodies and had been made available to staff.
  • The monitoring system to help ensure staff maintained their professional registration had been updated, in order to show that all staff were appropriately registered.
  • Disclosure and Barring Services (DBS) criminal records check and an assessment of the potential risks involved in using those staff without DBS clearance, had been obtained and risk assessments completed, where required.
  • Staff training had been reviewed and staff had received training in infection control, basic life support and fire safety. Dates for future training had been planned.
  • The practice had established a system to monitor and keep blank prescription forms safe.
  • Infection control risk assessments and audits were being carried out and staff were working with and adhering to the new infection control policies implemented by the practice.
  • Personnel records had been updated to ensure they contained evidence that appropriate checks had been undertaken, as well as job descriptions, for all staff employed.
  • Fire safety procedures and a fire risk assessment had been carried out.
  • The practice had established a Patient Participation Group (PPG) and used suggestions for improvements and made changes to the way it delivered services.
  • Effective systems to ensure policies and other documents to govern activity were kept up to date and routinely reviewed.
  • Clinical governance meetings were being held and minutes of such meetings were maintained.
  • Clinical audit systems had been improved to ensure they demonstrated completion of clinical audit cycles.
  • Effective systems to identify and reduce risk had been implemented and changes had been made to both policy, documentation and practice.

However there were areas of practice where the provider should make improvements:

  • Update the whistle blowing policy to include the contact details of the CQC and other relevant bodies for reporting concerns to.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

19 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Glebe Family Practice on 19 November 2014. During the inspection we gathered information from a variety of sources. For example, we spoke with patients, interviewed staff of all levels and checked that the practice had the correct systems and processes.

Overall the practice is rated as requires improvement. This is because we found the practice to require improvement for providing safe and well-led services which has led to this rating being applied to all patient population groups. It was good for providing an effective, caring and responsive service.

Our key findings were as follows:

  • The Glebe Family Practice had systems to monitor, maintain and improve safety and demonstrated a culture of openness to reporting and learning from patient safety incidents. The practice had policies to safeguard vulnerable adults and children who used services. Sufficient numbers of staff with the skills and experience required to meet patients’ needs were employed. There was enough equipment, including equipment for use in an emergency, to enable staff to care for patients and the practice had plans to deal with foreseeable emergencies.
  • Staff at The Glebe Family Practice followed best practice guidance and had systems to monitor, maintain and improve patient care. There was a process to recruit, support and manage staff. Equipment and facilities were monitored and kept up to date to support staff to deliver effective services to patients. The practice worked with other services to deliver effective care and had a proactive approach to health promotion and prevention.
  • Patients were satisfied with the care provided by The Glebe Family Practice and were treated with respect. Staff maintained patients’ dignity at all times. Patients were supported to make informed choices about the care they wished to receive and they felt listened to. The practice provided opportunities for patients to manage their own health, care and wellbeing and maximised their independence.
  • The practice was responsive to patients’ individual needs such as language requirements, mobility issues as well as cultural and religious customs and beliefs.
  • There was a clear leadership structure with an open culture that adopted a team approach to the welfare of patients and staff at The Glebe Family Practice. The practice used a variety of policies and other documents to govern activity but there was not an effective system to help ensure these were kept up to date. There was a GP lead for clinical governance and information governance. The practice had recruitment policies, however, these were not fully complied with.
  • Although the practice valued learning there was no clear system for monitoring training.

The areas where the provider must make improvements are:

  • Ensure patients’ records are held securely at all times.
  • Ensure the practice carries out appropriate checks prior to employment of staff including a Disclosure and Barring (DBS) criminal records check or an assessment of the potential risks involved in using staff without DBS clearance as well as review the monitoring and recording of staff registration with their relevant professional body.
  • Ensure the practice complies with national guidance on infection prevention and control.
  • Review its systems for monitoring safety and responding to risk as well as checking emergency equipment
  • Ensure policies, and other documents that govern activity at The Glebe Family Practice are kept up to date
  • Review their clinical audit cycle activity
  • Ensure all staff have an up to date job description that clearly defines their roles and responsibilities whilst working at the practice as well as review its staff appraisal system to ensure all staff are up to date with training.
  • Ensure that the practice canvasses and takes into account the views of patients and those close to them when planning and delivering services and has a patient participation group to gather patients’ views.

In addition the provider should:

  • Ensure all relevant staff have up to date knowledge of the Mental Capacity Act 2005.
  • Review its system to record practice meetings that involve staff from other service providers.
  • Review information about the practice to ensure it is up to date and available in relevant formats to all patients
  • Ensure that blank prescription forms are kept safe at all times.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice