Willowbrook Medical Practice in Sutton In Ashfield is a Doctors/GP specialising in the provision of services relating to diagnostic and screening procedures, family planning services, maternity and midwifery services, services for everyone, surgical procedures and treatment of disease, disorder or injury. The last inspection date here was 29th March 2017
Willowbrook Medical Practice is managed by Willowbrook Medical Practice.
Contact Details:
Address:
Willowbrook Medical Practice Brook Street Sutton In Ashfield NG17 1ES United Kingdom
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Willowbrook Medical Practice on 18 August 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the Month Year inspection can be found by selecting the ‘all reports’ link for Willowbrook Medical Practice on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 2 March 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 in our previous inspection on 18 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is now rated as good.
Our key findings were as follows:
The practice had a formalised process for staff meetings including governance issues.
Actions and outcomes from legionella testing had been followed up and work was ongoing.
Patient safety alerts, including estates and facilities alerts were received in practice. There was an effective process for dissemination and evidence to show these were acted on were applicable.
There was an effective process for reporting and recording significant events, incidents and near misses. All staff were aware of this and all analysis was shared with all staff.
Policies such as complaints policy and prescription security had been reviewed and updated were required. Staff understood the process and it was been followed.
Fridge temperatures were recorded and any outside the required range were reported and investigated as an incident. The practice were checking that drugs and vaccines were safe and fit for use.
Feedback from the national patient survey had been discussed with all staff and with the PPG to identify any areas for improvement.
The practice had reviewed processes and methods for identification of carers and the system for recording this. The practice had a carers champion who was responsible for maintaining the list and contacting them to offer support and advice for those that required it.
The registration of the regulated activity of maternity and midwifery services had not been completed on the day of inspection, however this was in the process of been actioned following the new registered manager application.
The areas where the provider should make improvement are:
Ensure regulated activity of maternity and midwifery is added when registered manager is in place.
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Willowbrook Medical Practice on 18 August 2016 . Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
There was an open and transparent approach to safety and a system in place for reporting and recording significant events however not all incidents were reported or shared with all staff.
Some risks to patients were assessed and well managed however several identified actions had not been completed.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
Patients said they were treated with compassion, dignity and respect.
Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
Patients said they found it difficult to make an appointment with a named GP however they could get an appointment on the day.
The practice had good facilities and was well equipped to treat patients and meet their needs.
There was a leadership structure and staff felt supported by management.
The practice was sponsoring a local scheme that provided meals at a susbidised cost using supermarket surplus. The practice had agreed to pay for 100 meals per month that would be given to the very underprivildeged and homeless.
The practice proactively sought feedback from staff and patients, which it acted on. However the results of the July 2016 national patient survey had not been fedback to the PPG or the GPs.
The provider was aware of and complied with the requirements of the duty of candour.
The practice did not have a process in place for identification and support for carers.
At the time of the inspection the provider was not registered for maternity and midwifery services. The provider said that they would rectify this.
The practice had a number of policies and procedures to govern activity however not all the policies were being adhered to.
There was an overarching governance framework which supported the delivery of the strategy and good quality care.
The practice proactively sought feedback from staff and patients, which it acted on
The areas where the provider must make improvement are:
Embed a formalised process for staff meetings including governance issues.
Ensure actions and outcomes from legionella testing are followed up and rectified.
Ensure patient safety alerts, including estates and facilities alerts received in practice are disseminated and acted on were applicable.
Ensure robust processes for reporting and recording significant events, incidents and near misses. Ensure all staff are aware of this and that all analysis is shared with relevant staff.
Ensure registration includes the regulated activity of maternity and midwifery services.
The areas where the provider should make improvement are:
Ensure policies in practice such as complaints policy and prescription security are followed and understood by all staff.
Ensure the registration is updated and applies for the registered activity for maternity and midwifery services.
Investigate errors with fridge temperatures and ensure that drugs and vaccines are safe and fit for use.
Review feedback from the national patient survey with all staff and identify any areas for improvement.
Review process and methods for identification of carers and the system for recording this. To enable support and advice to be offered to those that require it.
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