Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection visit of Northway Medical Centre, in April 2016. As a result of our comprehensive inspection a breach of legal requirements were found and the practice was rated as requires improvements for providing safe services. This was because we identified an area where the provider must make improvement and some areas where the provider should improve.

We carried out a focussed desk based inspection of Northway Medical Centre on 9 March 2017 to check that the provider had made improvements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Northway Medical Centre on our website at www.cqc.org.uk. Our key findings across all the areas we inspected were as follows:

• As part of our desk based inspection we noted improvements in the practices recruitment procedures, risk management and record keeping.

• For example, during our previous inspection in April 2016 we identified gaps in evidence to assure us that appropriate recruitment checks were undertaken prior to employment.

• As part of our desk based inspection we saw evidence to demonstrate that staff members had disclosure and barring checks (DBS) checks in place; this included clinical and non-clinical staff. We also saw that appropriate recruitment and induction processes were followed staff members such as locum GPs and members of the non-clinical team.

• During our inspection in April 2016 we found that the practice did not have a system in place to track and monitor the use of the prescription pads used for home visits. As part of our desk based inspection we saw that the practice had improved their prescription monitoring process to include prescription stationary used during home visits and we saw records to support this.

• When we inspected the practice in April 2016 we saw that the actions identified within the practices legionella risk assessment had not been completed, such as weekly temperature checks. As part of our desk based inspection we saw that the actions identified within the legionella risk assessment were completed in line with recommendations and records were kept to support this.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Northway Medical Centre on 14 April 2016. Overall the practice is rated as good.

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

• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Staff were aware of their responsibilities to raise and report concerns, incidents and near misses. Information about safety was recorded, monitored, reviewed and addressed. The practice had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.

• Staff regularly conducted reports and analysed data through ongoing reviews and audit work.

• Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs. Staff we spoke with said they felt valued, supported and that they felt involved in the practices plans.

• There were some arrangements for managing and mitigating risk. However, we identified that actions within the legionella risk assessment had not been completed.

• The practice offered a range of clinical services which included care for long term conditions and services were planned and delivered to take into account the needs of different patient groups to ensure flexibility, choice and continuity of care.

• We observed the premises to be visibly clean and tidy. Information for patients about the services available was easy to understand, accessible and available in a variety of formats.

• We found some gaps in the record keeping for staff files such as no record of references and registration with the appropriate professional body for the locum GP and were no records of disclosure and barring checks (DBS checks) for the healthcare assistants. We saw records to demonstrate that the practice had signed up to a group scheme and that they were in the early stages of having staff members DBS checked.

• Prescription stationery was securely stored, however the practice did not have a system in place to track and monitor the use of the prescription pads used for home visits.

• The practice had an active patient participation group which influenced practice development.

However there were areas of practice where the provider needs to make improvements.

The areas where the provider must make improvements are:

• Improve the overall management of Human Resources; ensure that robust recruitment procedures are in place for all staff as required, prior to working at the practice.

The areas where the provider should make improvement are:

• Ensure that the actions identified within the legionella risk assessment are completed as required to continue to manage potential risks.

• Ensure that prescription pads used for home visits are adequately tracked and monitored in line with national guidance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice