We carried out an announced comprehensive inspection at Winchmore Surgery on 18 May 2021, and a remote clinical review on 12 May 2021 to follow up on breaches of regulations. Overall the practice is rated Requires Improvement, with the following ratings for each key question:
Safe - Requires Improvement
Effective - Good
Caring - Good
Responsive – Good
Well-led - Requires Improvement
Why we carried out this inspection
This inspection was a comprehensive follow-up inspection to follow up on:
- Breaches of regulation found at our last inspection; and,
- Action the practice had taken in regard to areas where it should make improvements.
The practice was previously inspected on 28 November 2019. Following that inspection, the practice was rated Requires Improvement overall (and for the key questions including: Safe, Effective, Responsive and Well-led and Good for providing a Caring service) for issues relating to medicines management, Safety alerts, Fire drills, patient follow-up, prescription management, staff training, maintaining staff records, safe premises, Medication reviews, quality outcomes for childhood immunisations, patients with diabetes and hypertension, booking appointments and telephone access. It was also rated as requires improvement for population groups: People with long-term conditions; and Working age people (including those recently retired and students). It was rated good for all other population groups.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Winchmore 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 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 overall.
We rated the practice as Requires Improvement for providing safe services because:
- The practice was not recording evidence on patients records of regular blood test monitoring for all patients being prescribed the high-risk medicines: methotrexate, azathioprine and lithium.
- When issuing prescriptions for methotrexate the practice did not indicate the day of the week patients should take the medicine, contrary to a medicine’s safety alert.
- Medical alerts and minutes of meetings were distributed to all relevant staff, and copies of alerts were added to the shared computer files so all were able to access them. However, there was no requirement for staff to confirm they had received and read medical alerts or meeting minutes.
We rated the practice as Good for providing effective services because:
- The practice had implemented an effective system to ensure regular medicines and health reviews were undertaken for elderly patients and patients with gestational diabetes.
- Child immunisation uptake rates remained below the World Health Organisation (WHO) targets; however, the practice had significantly improved its performance.
We rated the practice as Good for providing caring services because:
Staff dealt with patients with kindness and respect and involved them in decisions about their care.
The practice carried out its own patient surveys to gain patient feedback.
- During the Covid-19 Pandemic:
- the practice was a vaccination’s hub for its own and other local practices’ patients. It had conducted a survey of patient’s experiences of attending the practice and found: 100% (165 out of 165 patients) responded positively about their overall experience of attending the practice.
- it had delivered in excess of 35,000 vaccinations to patients. It had achieved a 0% wastage, with every vaccine dose it received being used in the vaccination of a person attending for vaccination.
- During the 2020-2021 flu season the practice administered vaccinations to its patients. It had also conducted a survey and found: 97% (63 out of 65 patients) responded positively about their overall experience of attending the practice.
We rated the practice as Good for providing responsive services because:
- The practices’ own survey and the 2021 GP Patient Survey found significantly higher levels of patient satisfaction than at the time of our previous inspection.
We rated the practice as Requires Improvement for being well-led because:
- The practice had revised its policies and procedures. However, it did not always have clear and effective processes for ensuring safe care and treatment and managing risks, issues and performance. In particular, the practice procedures for distribution of medical alerts and minutes of meetings did not ensure all clinicians were made aware of these.
- Patient notes did not record up to date blood test monitoring for all patients being prescribed high-risk medicines.
We have rated this practice as Requires Improvement overall and Good for all population groups except for People with long-term conditions which we have rated as Requires Improvement.
The areas where the provider must make improvements are:
- Ensure care and treatment is provided in a safe way to patients.
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
- Consider recording whether do not attempt cardiopulmonary resuscitation (DNACPR) records are either subject to a review date, or state that the decision was indefinite.
- Continue to work to improve uptake by eligible patients of childhood immunisations and cervical screening.
- Work to improve its performance for its cervical screening programme.
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