The Care Quality Commission
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Archived: Fusehill Medical Practice

Overall: Good read more about inspection ratings

Fusehill Street, Carlisle, CA1 2HE (01228) 527559

Provided and run by:
SSP Health GPMS Ltd

All Inspections

31 March 2022

During a routine inspection

We carried out an announced inspection at Fusehill Medical Practice on 29 and 31 March 2022. Overall, the practice is rated as Good.

The ratings for each key question are:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

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

Why we carried out this inspection

This inspection was a comprehensive inspection to rate the practice following a change to their registration with CQC.

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 Good overall

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • Continue to look for ways to improve access to appointments for patients.
  • Continue work aimed at and in order to improve patient feedback around care.
  • Investigate whether patients who have been marked as having had a medication review completed have had all their medicines reviewed.
  • Improve the identification of carers on the practice list.

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 Care

N/A

During an inspection looking at part of the service

We carried out an announced review at Fusehill Medical Practice on 18 June 2021 to review the actions taken comply with Regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The practice was previously inspected in October 2020 in response to concerns and was issued with a requirement notice against the aforementioned regulation. At that time we did not consider the ratings of the practice due to our inspection methodology during the pandemic.

Why we carried out this review:

This review was a focused review of information without undertaking a site visit to follow up on:

  • Areas of concern, including a breach of regulation and ‘shoulds’ identified at the previous inspection.

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 reviews differently.

This review 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

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:

  • Action had been taken to address the gaps in systems to assess, monitor and manage risks to patient safety;
  • A locally-based GP had been appointed to the role of clinical director at the practice. This GP had management responsibilities but also undertook clinical sessions. This was in response to higher-than-average use of locum GPs and insufficient clinical oversight at the practice, which we saw in October 2020;
  • Designated lead roles had now been established for the safe handling of requests for repeat medicines and structured medicines reviews. The practice was working closely with the clinical commissioning group to improve in this area;
  • The clinical director provided continuous oversight to ensure there was a designated lead person to monitor referrals, discharge letters, and test results to make sure they were regularly checked and actioned;
  • The safeguarding register had been audited and updated and regular safeguarding meetings with other relevant agencies were taking place.

The areas where the provider should make improvements are:

  • Continue to work towards improving the number of patients who have received a timely medication review in line with their needs.

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 Care

01 Oct 2020

During an inspection looking at part of the service

We carried out an announced focused inspection at Fusehill Medical Practice on 1 October 2020 in response to information of concern.

The practice was previously inspected in September 2015 and was rated as good overall. The ownership and registration of the practice has since changed. Fusehill Medical Practice is now part of SSP Health GPMS Ltd in Lancashire. As this inspection was in response to a complaint this inspection has not considered the ratings of the practice.

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 gaps in systems to assess, monitor and manage risks to patient safety;
  • Designated lead roles had not been established for the safe handling of requests for repeat medicines and structured medicines reviews;
  • There was no designated lead person to monitor referrals, discharge letters, and test results to ensure they were regularly checked and actioned, and therefore no continuous oversight;
  • There was a higher-than-average use of locum GPs, which combined with a lack of lead roles meant there was insufficient clinical oversight at the practice;
  • The safeguarding register had not been audited and updated in the past 18 months;
  • We saw there were clinical audits carried out by the provider and the results were shared with the practice;
  • Patients with long-term conditions were offered a structured annual review to check their health and medicines needs were being met;
  • We reviewed the appointment system in real time on the day of the inspection and found there were a range of appointments available.

We are mindful of the impact of the Covid-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the Covid-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service to keep people safe and to hold providers to account where it is necessary for us to do so.

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.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Improve the arrangements for managing staff absences to reduce the risk of the practice being left short staffed;
  • Include locums in the sharing of learning from significant events;
  • Take steps to monitor completion of induction programmes by locum staff.

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 Care