The Care Quality Commission
  • Doctor
  • GP practice

Archived: Waters Edge Medical Centre

Overall: Good read more about inspection ratings

10 - 12 Leadsmithy Street, Middewich, Cheshire, CW10 9BH (01606) 544410

Provided and run by:
Waters Edge Medical Centre

All Inspections

05/03/2020

During a routine inspection

We carried out an announced comprehensive inspection at Waters Edge Medical Centre on 5 March 2020 as part of our inspection programme. At this inspection we followed up on breaches of regulations identified at a previous inspection on 4 October 2017.

This inspection looked at the following key questions:

Safe

Effective

Caring

Responsive

Well-led

At the last inspection in October 2017 we rated the practice as requires improvement for providing safe, effective and well-led services because: The recruitment procedures were not established and operated effectively to ensure only fit and proper persons were employed. Improvements were needed to systems and processes to ensure good governance in accordance with the fundamental standards of care. In particular, with regard to health and safety and systems and processes such as a periodic check of the electrical wiring system, long- term conditions recall system and safeguarding. The provider also needed to ensure persons employed in the provision of the regulated activity received the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

At this inspection we found that the provider had satisfactorily addressed the above areas. We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected

• information from our ongoing monitoring of data about services and

• information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.

  • Patients received effective care and treatment that met their needs.

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

  • The way the practice was led and managed promoted the delivery of good quality, person-centre care.

We saw an area of outstanding practice:

  • The practice had identified members of staff as champions for patients with cancer and for patients who had been bereaved or who acted as carers. The provider told us these patients were proactively contacted by the champions so they knew about the support available, were signposted to the most appropriate services, received timely intervention and the care they needed.


Whilst we found no breaches of regulation, the provider should:

  • Embed the updated child protection policy to code significant adults when concerns about a child have been identified.

  • Continue to monitor the system to add the date to patients’ records of any tests completed for the monitoring of high-risk medication.

  • Continue to monitor the updated system to make a daily record of the vaccine fridge temperature.

  • Continue to monitor records of checks of the cold-water systems in accordance with the legionella risk assessment.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

4 October 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Waters Edge Medical Centre on 4 October 2017. Overall the practice is rated as requires improvement.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However clinicians were not meeting to discuss learning outcomes and actions and therefore, relevant information was not being disseminated to the locum GPs working at the practice.

  • Not all risks to patients were assessed and managed.For example, those relating to staff recruitment checks, some health and safety checks and the summarising of new patient medical records and the lack of an effective recall system for patients with long-term conditions.

  • Staff were aware of procedures for safeguarding patients from the risk of abuse, however improvements were needed with regard to the information recorded in patient records.

  • The practice was experiencing significant staffing issues and was reliant on locum GPs and advanced nurse practitioners to provide services to patients.

  • The systems to monitor the training needs of staff were not effective and the system to ensure appraisals and staff personal development plans were carried out required improvement.

  • The overarching governance of the practice was ineffective and did not support the monitoring of the quality and safety of the service.

  • The electrical wiring system had not had a periodic check carried out to ensure it was safe.

  • Staff were aware of current evidence based guidance.

  • Patients said they were treated with compassion, dignity and respect. We saw staff treated patients with kindness and respect.

  • Services were planned and delivered to take into account the needs of different patient groups.

  • Information about services and how to complain was available. However, improvements were needed to ensure robust records were maintained to support learning and openness and transparency.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • The practice sought feedback from staff and patients, which it acted on.

  • The provider was aware of the requirements of the duty of candour.

The provider needs to make improvements.

Importantly, the provider must:

  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. In particular with regard to health and safety and systems and processes such as a periodic check of the electrical wiring system, long- term conditions recall system and safeguarding.

  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

In addition the provider should:

  • Review the safeguarding system to ensure complete and detailed information is recorded in patients records Continue to monitor the effectiveness of the meetings set up with other health and social care professionals with regard to safeguarding.

  • Put a system in place to ensure patients with long-term conditions are effectively monitored at regular intervals.

  • Regularly monitor the newly implemented fire safety systems to maintain staff and patient safety.

  • Introduce a system to allow the findings and actions arising from investigations into significant events to be consistently shared with staff. Record the action taken and date of review of all significant events to allow a comprehensive overview of issues arising and actions implemented.

  • Review the complaints system to ensure accurate records were maintained and actions taken clearly recorded.

  • Review the system in place that monitors the health and wellbeing of patients with mental health needs.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice