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Inspection Summary


Overall summary & rating

Good

Updated 11 July 2016

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection of this practice on 11 February 2015. A breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to;

  • Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – safe care and treatment.

From the inspection on 11 February 2015, the practice were told they must:

  • Ensure a coordinated approach to medicines management and that a system is in place to record the amount and type of medicines and vaccinations kept at the practice. All medicines and medical consumables, including those kept with emergency equipment, must be within their expiry dates and stored appropriately.

We undertook a desk top based focused inspection at Fishermead Medical Centre on 14 June 2016 to check that they had followed their plan and to confirm that they now met legal standards and requirements. This report only covers our findings in relation to those requirements found to be requiring improvement . You can read the report from our last comprehensive inspection, by selecting 'all reports' link for Fishermead Medical Centre on our website at www.cqc.org.uk

We found that on the 14 June 2016 the practice now had improved systems in place.

  • Practice specific protocols and procedures had been developed and implemented to manage risks associated with the handling and storage of medicines.
  • Systems to ensure that medicines were checked, stored securely and managed appropriately had been implemented and adhered to.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 11 July 2016

At our comprehensive inspection on 11 February 2015, we identified a breach of legal requirement. Improvements were needed to processes and procedures to ensure the practice provided safe services, in particular relating to the safe management and storage of medicines. During our desk based focused inspection on 14 June 2016 we found the practice had taken action to improve and the practice is rated as good for providing safe services.

Systems to ensure that medicines were checked, stored securely and managed appropriately were adhered to. We saw evidence that all medicines and medical consumables were routinely checked to ensure they were within their expiry dates and records of stock were held.

Effective

Good

Updated 18 June 2015

The practice is rated as good for effective. The practice reviewed, discussed and acted upon best practice guidance to improve the patient experience. There was a programme of clinical audit at the practice to further improve patient care. The practice provided a number of services designed to promote patients’ health and wellbeing. The practice took a collaborative approach to working with other health providers and there was multi-disciplinary working at the practice. There was a mixed response from clinical staff about the process used at the practice to obtain patient consent and the requirements of the Mental Capacity Act (2005). Following our inspection visit, the practice arranged training on this for all staff. The skills, abilities and development requirements of most staff were appraised.

Caring

Good

Updated 18 June 2015

The practice is rated as good for caring. On the day of our inspection visit, we saw staff interacting with patients in reception and outside consulting rooms in a respectful and friendly manner. There were a number of arrangements in place to promote patients’ involvement in their care. Throughout the period of our inspection process, patients told us they felt listened to and included in decisions about their care. Accessible information was provided to help patients understand the care available to them.

Responsive

Good

Updated 18 June 2015

The practice is rated as good for responsive. There were services targeted at those most at risk such as older people and those with long term conditions. The premises and services were adapted to meet the needs of people with disabilities. At the time of our inspection visit, patients reported adequate access to the practice. Appointments, including those required in an emergency were available. Some additional access to services for those who found attending in normal working hours difficult was available. Methods were available for patients to leave feedback about their experiences. The practice demonstrated it responded to patients’ comments and complaints and where possible, took action to improve the patient experience.

Well-led

Good

Updated 18 June 2015

The practice is rated as good for well-led. Staff felt engaged in a culture of openness and consultation. The management and meeting structure ensured that clinical decisions were reached and action was taken. There was a process in place for identifying and managing risks and ensuring these were acted upon. The practice’s annual review of incidents and events consolidated their learning from them. The practice sought feedback from patients and staff and listened to representatives of the patient population. Staff were supported by management and a system of policies and procedures that governed activity.

Checks on specific services

Older people

Good

Updated 11 July 2016

Following our comprehensive inspection on 11 February 2015 we rated the practice as good for the population group of older people. We did not review any evidence during our desk based focussed inspection to alter this rating.

People with long term conditions

Good

Updated 11 July 2016

Following our comprehensive inspection on 11 February 2015 we rated the practice as good for the population group of people with long-term conditions. We did not review any evidence during our desk based focussed inspection to alter this rating.

Families, children and young people

Good

Updated 11 July 2016

Following our comprehensive inspection on 11 February 2015 we rated the practice as good for the population group of families, children and young people. We did not review any evidence during our desk based focussed inspection to alter this rating.

Working age people (including those recently retired and students)

Good

Updated 11 July 2016

Following our comprehensive inspection on 11 February 2015 we rated the practice as good for the population group of working age people (including those recently retired and students). We did not review any evidence during our desk based focussed inspection to alter this rating.

People whose circumstances may make them vulnerable

Good

Updated 11 July 2016

Following our comprehensive inspection on 11 February 2015 we rated the practice as good for the population group of people whose circumstances may make them vulnerable. We did not review any evidence during our desk based focussed inspection to alter this rating.

People experiencing poor mental health (including people with dementia)

Good

Updated 11 July 2016

Following our comprehensive inspection on 11 February 2015 we rated the practice as good for the population group of people experiencing poor mental health (including people with dementia). We did not review any evidence during our desk based focussed inspection to alter this rating.