The Care Quality Commission
  • Doctor
  • GP practice

Alderwood Medical Practice

Overall: Good read more about inspection ratings

Longford Road, Cannock, Staffordshire, WS11 1QN (01543) 574402

Provided and run by:
Alderwood Medical Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Alderwood Medical Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Alderwood Medical Practice, you can give feedback on this service.

13 July 2021

During an inspection looking at part of the service

We carried out an announced inspection at Alderwood Medical Practice on 13 July 2021. Overall, the practice is rated as Good .

The ratings for each key question are as follows:

Safe - Good

Effective -Good

Caring – Good

Responsive – Good

Well-led – Good

We carried over the ratings from the last inspection for the caring and responsive key questions.

Following our previous inspection on 28 May 2019, the practice was rated Requires Improvement overall and for the key questions of safe and well-led and good for effective.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Alderwood Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused follow-up inspection to follow up on:

Two Requirement Notices served for breaches in:

  • Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
  • Regulation 17 Health and Social Care Act (RA) Regulations 2014 Good governance.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A site visit

Our findings

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.
  • The practice maintained a register of vulnerable adults.
  • The system for identifying and recording and analysing significant events had improved.
  • The system fo tracking prescription stationary had been implemented and was effective.
  • 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 adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
  • Governance arrangements had been strengthened.

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

  • Implement the staff well-being plan and work to improve staff morale.
  • Continue to work towards establishing a patient participation group.

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

28/05/2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Alderwood Medical Practice on 28 May 2019. We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions: safe, effective and well-led. 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 previously carried out a focused inspection at Alderwood Medical Practice on 31 January 2018. The overall rating remained good with requiring improvement in providing safe services.

A breach of legal requirement was found, and requirement notice was served in relation to safe care and treatment. We also made four good practice recommendations. The report on the January 2018 inspection can be found by selecting the ‘all reports’ link for Alderwood Medical Practice on our website at www.cqc.org.uk

At the last inspection in January 2018, we rated the practice as requires improvement for providing safe services because:

  • The practice had not carried out a risk assessment to reflect the emergency medicines required in the practice for the range of treatments offered and the conditions treated.
  • The practice had not fully assessed the environmental risks or control measures.

At this inspection, we found that the provider had satisfactorily addressed these areas.

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

The practice is rated as requires improvement for providing safe services because:

  • One of the staff recruitment files we reviewed did not contain satisfactory evidence of conduct in previous employment.
  • Not all staff had received up-to-date essential training to include certified fire safety, and safeguarding children.
  • There was not an effective system in place for receiving and acting on safety alerts.
  • The practice did not have a vulnerable adult register or formal arrangements in place for sharing safeguarding information with external agencies to include the health visiting team or out of hours services.
  • An incident we identified had not been considered as a significant event. There was no regular analysis of significant events to identify common trends and improve the quality of patient care from lessons learnt.
  • A system to track prescription stationary throughout the practice was not in place.

We rated the practice good for providing effective services because:

  • The practice understood the needs of its population and tailored services in response to those needs. The practice had reviewed their skill set and recruited an additional advanced nurse practitioner (ANP) in addition to hosting a physician associate training programme in conjunction with a local university.
  • A pictorial booklet had been developed and easy read booklets obtained to help prepare and support patients with a learning disability during their appointments and health reviews. The health care assistant supported these patients.
  • Staff were consistent and proactive in helping patients to live healthier lives.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Clinical audits demonstrated quality improvement.

We rated the practice requires improvement for providing a well-led service because:

  • The practice was in the process of implementing leadership changes. Staff felt supported by the management team, proud to work at the practice and comfortable to raise concerns. However, arrangements for clinical leadership and overall governance structures required further development and changes fully embedded to improve patient care.
  • Staff were supported in their roles and with their professional development.
  • There was a lack of structured formal meetings to communicate and share information.
  • The practice had a number of policies and procedures to govern activity. However, not all policies were available or comprehensive.
  • The practice did not have an established patient participation group to proactively seek feedback from patients.
  • A higher percentage of respondents to the GP patient survey 2018 responded positively to the overall experience of their GP practice compared to local and national averages.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a consistent safe way to patients
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Ensure all staff complete outstanding essential training.
  • Provide the fire marshal with training.
  • Improve the awareness and uptake of the patient participation group.
  • Develop and improve governance structures.
  • Carry out a regular analysis of significant events to identify any common trends, maximise learning and help mitigate further errors.
  • Develop a practice vision and values.
  • Establish a comprehensive log of policies and procedures to govern practice.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of General Practice

31 January 2018

During an inspection looking at part of the service

We previously carried out an announced comprehensive inspection at Alderwood Medical Practice, previously registered as Dr A Verma & Dr TM Campbell, on 12 January 2017. The overall rating for the practice was Good with Requires Improvement for providing safe services. The full comprehensive report on the 12 January 2017 inspection can be found by selecting the ‘all reports’ link for Alderwood Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 31 January 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 12 January 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At this inspection we found that the practice had not addressed all of the concerns previously identified and therefore continues to be rated as Requires Improvement for providing safe services.

Our key findings were as follows:

  • There were systems in place to mitigate risks to patients prescribed high risk medicines.

  • Health and safety policies and protocols to identify, assess and minimise risk to patients and staff had been developed but required further improvement.

  • The process for documenting the action taken in response to external alerts that may affect patient safety had improved.

  • The healthcare assistant was now working under patient specific directions, a written instruction signed by a prescriber for medicines to be administered to a named patient after the prescriber has assessed the patient on an individual basis.

  • The practice had reviewed and updated their policy for the safeguarding of vulnerable adults but this required additional information.

  • The practice had implemented processes to demonstrate that the physical and mental health of newly appointed staff had been considered to ensure they were suitable to carry out the requirements of their role.

  • An effective prescription tracking system to had been implemented to help minimise the risk of fraud.

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

Importantly, the provider must:

  • Ensure care and treatment is provided in a safe way to patients. In particular, review and complete a formal risk assessment to demonstrate how risks to patients will be mitigated in the absence of suggested emergency medicines held at the practice and further develop the health and safety risk assessments.

The provider should:

  • Date all policies to ensure they are reviewed and updated within an appropriate time frame.

  • Review and update the practice’s safeguarding vulnerable adult’s policy to reflect the latest guidance.

  • Document actions taken in response to external medicine safety alerts and ensure they are fully documented in patients’ records.

  • Submit an application to CQC in relation to the change in GP partnership.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Dr A Verma and Dr T M Campbell on 12 January 2017. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Learning was shared with staff and reported to external agencies when required.
  • Required recruitment checks had been made before a member of staff was employed to work at the practice. However, the physical and mental health of newly appointed staff had not been considered.
  • The systems in place to mitigate risks to patients who took high risk medicines were not always effective.
  • An overarching training matrix and policy was in place to monitor that all staff were up to date with their training needs and received regular appraisals.
  • Patients said they found urgent appointments were available the same day.
  • Feedback from patients about their care was consistently positive and was reflected in the national patient survey results; last published in July 2016.
  • The practice had reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group (CCG) to secure improvements to services where these were identified.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice actively reviewed complaints and how they are managed and responded to, and made improvements as a result.
  • The practice had a written set of objectives and values supported by a written practice development plan that reflected this strategy and ensured the future direction of the practice was monitored and evaluated.
  • The practice had visible clinical and managerial leadership. Most governance and audit arrangements were effective but we found some areas that required ongoing review.

The areas where the provider must make improvement are:

  • Ensure that systems to mitigate risks to patients prescribed high risk medicines are fully effective.
  • Implement patient specific directions for the healthcare assistant.
  • Further develop the health and safety policies and protocols to identify, assess and minimise risk to patients and staff using risk assessments and a review of the process for responding to alerts.

The areas where the provider should make improvement are:

  • Review the process of responding to alerts to include a record that appropriate actions have been completed.
  • Complete the practice policy for the safeguarding of vulnerable adults.
  • Implement processes to demonstrate that the physical and mental health of newly appointed staff have been considered to ensure they are suitable to carry out the requirements of the role.
  • Implement an effective prescription tracking system to minimise the risk of fraud.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice