The Care Quality Commission
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Archived: Victoria Medical Practice

Overall: Good read more about inspection ratings

Wellington Road, Dewsbury, West Yorkshire, WF13 1HN (01924) 351660

Provided and run by:
Malling Health (UK) Limited

All Inspections

5 April 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Victoria Medical Practice on 21 September 2016. The overall rating for the practice was good. However, a breach of the legal requirements was found which resulted in the practice being rated as requires improvement for providing safe services. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for Victoria Medical Practice on our website at www.cqc.org.uk.

In addition to the breach of regulation, at the inspection on 21 September 2016 we also said the practice should consider the following areas:

  • The practice should review the arrangements for regularly reviewing the immunisation status of care workers and providing vaccinations to staff as necessary in line with current guidance.
  • The practice should review their arrangements for clinical audit at the practice. Clinical audit should be clearly linked to patient outcomes, monitored for effectiveness and comprise of two or more cycles to monitor improvements to patient outcomes.
  • The practice should take steps to improve their identification of patients who are carers, in order to be able to provide them with any additional support they may require.

This inspection was an announced focused inspection carried out on 5 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach of regulations that we identified in our previous inspection on 21 September 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is now rated as good for providing safe services.

Our key findings were as follows:

  • The practice had updated their new patient registration form to include questions about carers and those who were cared for. We saw that posters and leaflets were available for carers. The practice had identified 1% of their patient list as carers. However, the national general practice profile shows that there were significantly less people registered with the practice aged over 44 than the CCG or national average.
  • The practice told us of their plans to complete a second cycle of the audits previously undertaken, but that the timescale for the completion of this had not yet been reached. We saw that audits were ongoing.

The areas where the provider should make improvement are:

  • The provider should continue to review their arrangements for clinical audit at the practice. Clinical audit should be clearly linked to patient outcomes, monitored for effectiveness and comprise of two or more cycles to monitor improvements to patient outcomes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

21 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Victoria Medical Practice on 21 September 2016. Overall the practice is rated as good. The practice is rated as requires improvement for safety.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • Risks to patients were mostly assessed and well managed, with the exception of those relating to the vaccine refrigerator and cold chain.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • The practice must ensure staff understand and follow practice policies and procedures for the management of the vaccine refrigerator and the preservation of the cold chain.

The areas where the provider should make improvement are:

  • The practice should review the arrangements for regularly reviewing the immunisation status of care workers and providing vaccinations to staff as necessary in line with current guidance.
  • The practice should review their arrangements for clinical audit at the practice. Clinical audit should be clearly linked to patient outcomes, monitored for effectiveness and comprise of two or more cycles to monitor improvements to patient outcomes.
  • The practice should take steps to improve their identification of patients who are carers, in order to be able to provide them with any additional support they may require.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice