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Reports


Inspection carried out on 24 January 2019

During an inspection to make sure that the improvements required had been made

This practice is rated as Good overall. (Previous rating 5 June 2018 – Good)

The well-led key question at this inspection is rated as: Good.

We carried out an announced focused inspection at North Park Health Centre on 24 January 2019 to follow up a breach of regulation from our last inspection carried out on 5 June 2018.

The full comprehensive report on the June 2018 inspection can be found by selecting the ‘all reports’ link for North Park Health Centre on our website at .

At the previous inspection of 5 June 2018 we rated the practice as ‘good’ overall but as ‘requires improvement’ in the well-led key question. We identified a breach of Regulation 17 HSCA (RA) Regulations 2014 - Good governance. This was because the systems and processes to support good governance were not always clearly set out and there was not always sufficient leadership oversight of some of the systems and processes in place.

This inspection was a follow up inspection to confirm that the provider had carried out their plan to meet the legal requirements. Our key findings were as follows:

  • The provider had taken action to meet the breach of regulation.
  • The systems and processes in place to ensure good governance had been reviewed and improved.

We also looked at action taken in response to the recommendations we had made to the provider following the last inspection visit. We found:

  • A formalised process had been put in place to demonstrate that staff were provided with appropriate support, training, appraisal and professional development.
  • An up to date record of staff training had been produced to ensure the provider had an overview of the training staff had undergone and to identify any gaps in training.
  • A new system had been introduced to demonstrate the management of complaints and the actions taken following receipt of complaints.
  • Staff had access to regularly reviewed policies and procedures to ensure they were provided with up to date and accurate guidance to support them in their work.
  • Meetings, including clinical and governance were being recorded in greater detail to reflect the discussions and decisions made.
  • A new log for recording/accounting for blank prescriptions had been introduced.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the evidence table for further information.

Inspection carried out on 05/06/2018 to 05/06/2018

During a routine inspection

This practice is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at North Park Health Centre on 5 June 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had systems in place to manage risk.
  • When safety incidents did happen, the practice learned from them and improved their processes.
  • Systems were in place to deal with medical emergencies and staff were trained in basic life support.
  • Procedures were in place to prevent and control the spread of infection.
  • There were regular checks on the environment and on equipment used.
  • Clinical audits were carried out and the results of these were used to improve outcomes for patients.
  • The practice reviewed the appropriateness of the care it provided and care and treatment was delivered according to evidence based guidelines in the areas we looked at.
  • Data showed that the practice was performing in line with local and national averages for most aspects of the care and treatment provided.
  • Staff told us they felt supported in their roles and with their professional development.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • The majority of patients we received feedback from told us they had seen improvements to the appointments system and they had better access to clinicians.
  • Systems for clinical governance were not always clearly established.
  • The provider did not have sufficient leadership oversight in areas such as; support to staff, staff training and ensuring staff had access to up to date policies and procedures.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Ensure formalised processes are in place to demonstrate that staff are provided with appropriate support, training, appraisal and professional development.
  • Maintain an up to date record of staff training to ensure the provider has an overview of the training staff have undergone and to identify any gaps in training.
  • Ensure appropriate systems are in place for demonstrating the actions taken following receipt of complaints.
  • Review policies, procedures and documents available to staff to ensure these provide staff with guidance that is up to date and accurate.
  • Ensure meetings, including clinical and governance meetings, are appropriately documented.

Review the arrangements for recording/accounting for prescriptions.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice