Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Fordhouses Medical Centre on 13 July 2016. A total of two breaches of legal requirements were found. After the comprehensive inspection, the practice was rated as requires improvement.

We issued requirement notices in relation to:

• Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Safe care and treatment.
• Regulation 17 HSCA (RA) Regulations 2014 Good Governance

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Fordhouses Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 April 2017 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 at our previous inspection on 13 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. There was a lack of detail in records to confirm discussions that had taken place.
• Risks to patients were assessed and well managed. The practice had improved its procedures to ensure appropriate recruitment checks had been completed, DBS checks had been carried out.
• Staff training records had been updated and staff appraisals, competency checks and supervision completed.
• Procedures had been reviewed and systems introduced to ensure the safe management of medicine safety alerts.
• A full legionella risk assessment had been completed and any recommendations made acted on.
• Complaint leaflets were appropriately placed to ensure patients had easy access.
• The practice had looked at ways to pro-actively identify carers and establish what support they need. This included ensuring information was readily available and checking with patients when they attended appointments.

At this inspection we found that the practice had addressed all the concerns raised and is now rated as good for providing safe and well-led services.

There were areas of practice where the provider should still make improvements:

• Ensure national guidelines for children who do not attend for hospital events are followed at all times.
• Ensure that records detailing significant events are fully completed to confirm the proactive and ongoing review of all events and include details of who the learning from events were shared with.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Fordhouses Medical Centre on 13 July 2016. A total of two breaches of legal requirements were found. After the comprehensive inspection, the practice was rated as requires improvement.

We issued requirement notices in relation to:

• Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Safe care and treatment.
• Regulation 17 HSCA (RA) Regulations 2014 Good Governance

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Fordhouses Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 April 2017 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 at our previous inspection on 13 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. There was a lack of detail in records to confirm discussions that had taken place.
• Risks to patients were assessed and well managed. The practice had improved its procedures to ensure appropriate recruitment checks had been completed, DBS checks had been carried out.
• Staff training records had been updated and staff appraisals, competency checks and supervision completed.
• Procedures had been reviewed and systems introduced to ensure the safe management of medicine safety alerts.
• A full legionella risk assessment had been completed and any recommendations made acted on.
• Complaint leaflets were appropriately placed to ensure patients had easy access.
• The practice had looked at ways to pro-actively identify carers and establish what support they need. This included ensuring information was readily available and checking with patients when they attended appointments.

At this inspection we found that the practice had addressed all the concerns raised and is now rated as good for providing safe and well-led services.

There were areas of practice where the provider should still make improvements:

• Ensure national guidelines for children who do not attend for hospital events are followed at all times.
• Ensure that records detailing significant events are fully completed to confirm the proactive and ongoing review of all events and include details of who the learning from events were shared with.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We previously inspected Fordhouses Medical Centre 24 June 2013. At the time we found that arrangements were in place to ensure people using the service were supported to express their views. Audits were carried out to check safety and suitability of equipment. However there were no systems in place to monitor and review any actions required to address issues found, and to complete the quality assurance process. We judged that this had a minor impact on patients who used the service.

We set compliance actions and told the provider to improve. The provider sent us an action plan following our visit which recorded the actions taken to address the issues raised.

At this inspection visit we looked to see what improvements had been made. We met the GP (who was the provider); we spoke with the practice manager, two staff members and one patient who was visiting the surgery at the time of our inspection. There was also a branch surgery at another location. We visited this location to ensure improvements had also been made to the branch surgery.

We gave short notice of this inspection so that any disruption to people's care and treatment were minimised. At this inspection We found that the practice had taken action to improve the service patients received

During our inspection on 24 and 25 June 2013, people we spoke with had mixed views about the care they received. One person told us: “The nurses are lovely.” Another person told us they were unhappy with long waiting times for appointments.

People told us that staff treated them respectfully. We saw that reception staff spoke politely to people and consultations were carried out in private treatment rooms. Staff received training in mandatory core subjects

Information was clearly displayed for people, including health promotion, access to support services and information about the practice and the services provided.

Arrangements were in place to ensure people using the service were supported to express their views. Audits were carried out to check safety and suitability of equipment. However there were no systems in place to monitor and review any actions required to address issues found, and to complete the quality assurance process.