Background to this inspection
Updated
20 May 2019
Water Eaton Health Centre provides a range of primary medical services including minor surgical procedures, to the residents of Bletchley from its location at Fern Grove, Bletchley, MK2 3HN. It is part of the NHS Milton Keynes Clinical Commissioning Group (CCG). The practice population is predominantly white British with a higher than average population of patients in the below 39 year age range.
National data indicates the area is one of high deprivation. The practice has approximately 6,300 patients with services provided under a General Medical Services (GMS) contract (which is a nationally agreed contract between general practices and NHS England for delivering general medical services to local communities).
There is one male Lead GP who is registered with the CQC as the sole provider of services. The practice utilises locum doctors regularly to provide additional clinical support and to ensure regular patient access to a female GP. The nursing team consists of one minor illness trained nurse practitioner, two practice nurses and a phlebotomist who are all female. The practice also employs a female pharmacist. There is a team of administrative and reception staff all led by the practice manager. Members of the community midwife and health visiting team operate regular clinics from the practice location. Trust community staff (District nurses) are also based at the premises.
The practice operates from a single storey purpose built property shared with a dental surgery. There is a car park outside the surgery, with disabled parking available. The practice is open from 8am to 6.30pm Mondays to Fridays and offers extended opening hours from 7am to 8am on Mondays, Wednesdays and Thursdays.
When the practice is closed out of hours services are provided by Milton Keynes Urgent Care Services and can be contacted via the NHS 111 service.
The practice provides family planning, surgical procedures, maternity and midwifery services, treatment of disease, disorder or injury and diagnostic and screening procedures as their regulated activities.
Updated
20 May 2019
We carried out an announced comprehensive inspection of Water Eaton Health Centre on 2 October 2018. The overall rating for the practice was inadequate and the practice was placed into special measures.
We undertook a focused inspection in February 2019 to follow up on warning notices we issued to the provider in relation to Regulation 13 Safeguarding service users from abuse and improper treatment and Regulation 17 Good governance. During the inspection in February 2019 we found the provider had made significant improvements to address the concerns identified in the warning notices issues and was compliant with both Regulation 13 and Regulation 17.
From the inspection on 2 October 2018, the practice was told they must:
- Ensure care and treatment is provided in a safe way to patients.
- Ensure patients are protected from abuse and improper treatment. Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
In addition, the practice was told they should:
- Continue to work in line with the recently revised system for managing safety alerts ensuring records are kept to support appropriate dissemination and discussion of alerts.
- Continue with efforts to identify and support carers within the practice population.
- Continue with efforts to improve patient satisfaction with particular regard to the areas highlighted in the results of the national GP patient survey as being in need of improvement.
- Review registration processes to ensure that all patients, including those with no fixed abode are able to access care and treatment when needed.
- Continue to encourage patients to attend appointments in relation to national screening programmes.
The inspection reports from the October 2018 and February 2019 inspections can be found by selecting the ‘all reports’ link for Water Eaton Health Centre on our website at .
This inspection was undertaken following the period of special measures and was an announced comprehensive inspection at Water Eaton Health Centre undertaken on 1 April 2019 as part of our inspection programme to follow up on concerns identified at our previous inspection.
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 requires improvement for all population groups.
The practice is rated as requires improvement for providing responsive services because results of the national GP patients survey demonstrated the practice was performing significantly below local and national averages for questions relating to access.
Our key findings were as follows:
- The practice had continued to comply with the warning notices we issued and had taken the action needed to comply with the legal requirements.
- Systems in place to safeguard children and vulnerable adults had been improved.
- Evidence of pre-employment checks was now available and all staff had a disclosure and barring service (DBS) check.
- Measures had been put in place to ensure staff competencies prior to employment.
- Training records for staff were maintained and all mandatory training had been completed according to practice policy. However, training records for one locum were incomplete.
- Records of significant events and complaints were maintained and handled according to practice policy. Areas of learning and improvement were shared and actions taken where needed.
- Processes had been implemented to ensure the management of safety alerts received.
- Governance arrangements in the practice had been strengthened. Meetings were formalised and policies and procedures had been updated and reviewed.
- Much of the improvement work had been undertaken by the practice manager and administrative team, with the support of the local Clinical Commissioning Group.
- The practice advised of ongoing strategic and succession planning to ensure the future sustainability of the practice.
Whilst we found no breaches of regulations, the provider should:
- Record all staff training in accordance with practice polices, including training records for locum staff.
- Continue with efforts to improve patient satisfaction with particular regard to the areas highlighted in the results of the national GP patient survey as being in need of improvement.
- Ensure adequate leadership support is provided to the practice manager to support the sustainability of improvements made.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.
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