Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection visit of Woodsetton Medical Centre, in December 2015. As a result of our comprehensive inspection breaches of legal requirements were found and the practice was rated as requires improvements for providing safe services. This was because we identified areas where the provider must make improvement and some areas where the provider should improve.

We carried out a focussed desk based inspection of Woodsetton Medical Centre on 19 December 2016 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 Woodsetton Medical Centre on our website at www.cqc.org.uk. Our key findings across all the areas we inspected were as follows:

• We noted that since our comprehensive inspection took place in December 2015, risks associated with infection control, health, safety and fire had been formally assessed and were well managed. We saw records which supported this as part of our desk based inspection, in addition to supporting audits and actions implemented to embed improvements.

• During our previous inspection we noted that a permanent practice nurse had not been in place since April 2015. A nurse practitioner was successfully recruited at the practice and remained in post since April 2016. The practice expressed the appointment of the nurse prescriber supported them to ensure that patients needs and circumstances were met.

During our previous inspection we noted gaps in the practices systems and processes for monitoring emergency equipment and medicines. As part of our desk based inspection we noted effective arrangements were in place for monitoring emergency equipment and emergency medicines, as well as improved business continuity systems.

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 Woodsetton Medical Centre on 8 December 2015. Overall the practice is rated as good.

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

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.

• Arrangements were in place to safeguard children and vulnerable adults from abuse that reflected relevant legislation and local requirements.

• Formal risk assessments had not been completed to assess risks across a number of areas including health, safety and fire. While we observed the premises to be visibly clean and tidy, we found some gaps in the management of infection control.

• Whilst the practice was trying to recruit for a vacant practice nurse role we noticed some gaps in the provision of the service.

• The practice did not have a documented business continuity plan in place for major incidents such as power failure or building damage. The practice did not keep up to date records to evidence that there were systems in place to monitor the use of the emergency equipment and emergency medicines

• Clinical audits were carried out to demonstrate quality improvement and to improve patient care and treatment.

• Throughout the inspection process we noticed a theme regarding delays in accessing appointments over the phone.

• Information about how to complain was available and easy to understand and evidence showed that the practice responded quickly to issues raised.

• There were disabled facilities and translation services available.

The areas where the provider must make improvement are:

• Assess and manage risks associated with health and safety of the premises, fire risk and risk associated with infection control including control of substances hazardous to health and legionella.

• Ensure emergency medicines and equipment is regularly checked and ensure records are kept to monitor this.

The areas where the provider should make improvement are:

• Consider the scope of the practice nurse role and continue with recruitment processes to ensure the practice meets the needs and circumstances of people using the service.

• Develop a plan of business continuity to support the practice in event of a major incident.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice