We carried out a review of the data available to us about Colby Medical Centre Ltd 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 Colby Medical Centre Ltd, you can give feedback on this service.
We carried out an announced comprehensive inspection of Colby Medical Centre on 12 September 2018 as part of our inspection programme. The overall rating for the practice was good, however the practice was rated as requires improvement for providing responsive services. The full comprehensive report on the September 2018 inspection can be found by selecting the ‘all reports’ link for Colby Medical Centre on our website at , along with previous reports that have been undertaken.
This inspection was carried out as a desk based focussed inspection on 19 September 2019 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 12 September 2018. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.
Overall the practice is now rated as Good.
Our key findings were as follows:
The provider had acted on the recommendations made at the last inspection. This included:
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
This practice is rated as Good overall. (Previous rating September 2017 - Inadequate)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Requires Improvement
Are services well-led? – Good
We carried out an announced comprehensive inspection at Colby Medical Centre on 12 September 2018 as a follow-up inspection on breaches of regulations.
This was the third follow-up comprehensive inspection completed at the service.
At an inspection in January 2016 we rated the practice as ‘requires improvement’ in providing safe, effective and well led services. The practice was therefore rated as ‘requires improvement’ overall. We issued two requirement notices to the provider relating to recruitment and staffing levels. The provider sent us an action plan and assurances that they would mitigate any risks identified.
We carried out a follow-up inspection to that inspection out on 28 September 2017 to check whether that the provider had met their plan to meet the legal requirements, the report was published in March 2018. The findings were that whilst the provider had taken some action to meet the legal requirement notices, other issues highlighted in the previous 2016 report had not been addressed and there were other areas of concern identified. As a result, the practice was rated as inadequate in the safe and well-led domains and requires improvement in the effective domain. This meant the practice was rated inadequate overall and placed into special measures. The provider sent us an action plan and assurances that they would mitigate the risks identified.
We carried out a comprehensive follow-up inspection on 12 September 2018 to check that the provider had met their plan to meet the legal requirements and review whether there were sufficient improvements to take the practice out of special measures.
The findings of this inspection were sufficient improvements to take the practice out of special measures and the practice is now rated as Good overall.
The areas where the provider must make improvements as they are in breach of regulations:
The areas where the provider should make improvements are:
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice
We carried out an announced comprehensive inspection at Colby Medical Centre on 29 January 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 29 January 2016 inspection can be found by selecting the ‘all reports’ link for Colby Medical Centre on our website at www.cqc.org.uk.
At our previous inspection in January 2016 we rated the practice as ‘requires improvement’ in providing safe, effective and well led services. The practice was therefore rated as ‘requires improvement’ overall. We issued two requirement notices to the provider relating to recruitment and staffing levels. The provider sent us an action plan and also assurances that they would mitigate any risks identified.
This inspection visit was carried out on 28 September 2017 to check that the provider had met their plan to meet the legal requirements. The findings of this inspection were that whilst the provider had taken some action to meet the legal requirement notices, other issues highlighted in the previous report had not been addressed and there were other areas of concern identified. As a result the practice has been rated as inadequate.
Our key findings were as follows:
Some improvements had been made to the recruitment process to ensure patients were treated and cared for by appropriately skilled and competent staff.
Some improvements had been made to support provided to staff through the appraisal system. However further improvement was needed to ensure clinical support arrangements for the Advanced Nurse Practitioner and Nurse Clinician were formalised.
Some improvements had been made to the way significant events were managed but we found similar issues to those identified in the last inspection. For example, a periodic review of events to determine trends was not in place. We saw two examples where the provider had failed to recognise an event as a significant event and therefore they had not taken action to investigate the matter or to put systems in place to prevent a reoccurrence.
Medical equipment had been tested and calibrated since the last inspection.
There were gaps in medicines management systems. For example, a recent medication update had not been actioned. There was no system to monitor uncollected prescriptions to ensure vulnerable patients receive their medication in a timely manner. The monitoring system for emergency medicine expiry dates required improvement.
Staff understood their responsibilities in relation to safeguarding. However, the systems in place did not capture relevant information on patient records to alert clinicians that patients were subject to any part of the child protection process.
Clinicians were not accessing the most recent guidance to support the appropriate and safe treatment of patients.
We found examples where the practice had not followed up instructions in correspondence from hospitals and therefore actions had not been taken to provide necessary treatment and monitoring of patients.
At the previous inspection and at this inspection there was limited evidence that the clinical audits undertaken demonstrated quality improvement.
The practice had good facilities, including disabled access. It was well equipped to treat patients and meet their needs. Infection control practices were in place and there were regular checks on the environment and on equipment used.
Access to the service was monitored to ensure it met the needs of patients.
There was a system in place to manage complaints.
Staff felt supported. They had access to training and development opportunities appropriate to their roles.
Patients said they were treated with compassion, dignity and respect. We saw staff treated patients with kindness and respect.
The provider needs to make improvements.
Importantly, the provider must:
Ensure care and treatment is provided in a safe way to patient’s particular regard to the monitoring of emergency drugs, patients on high risk drugs and the communication and management of correspondence.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. To ensure patients receive safe and appropriate care.
In addition the provider should:
Review the safeguarding system to ensure patient records alert staff if the patient is subject to any part of child protection processes.
Review the use of care planning to support the most vulnerable patients within the practice.
Continue to monitor the staff recruitment and retention process to ensure appropriate checks are carried out to promote the safety and wellbeing of patients.
Introduce a system to monitor uncollected prescriptions to ensure vulnerable patients receive their medication in a timely manner.
Review how clinicians accessed clinical guidance to ensure it was the most recent to support the appropriate and safe treatment of patients.
We are now taking further action in relation to this provider and will report on this when it is completed.
I am placing this service in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.
Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Colby Medical Centre Ltd on the 29 January 2016. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
Systems were in place to ensure incidents and significant events were identified, investigated and reported. Staff understood their responsibilities to raise concerns, however not all incidents discussed with the inspection team had been reported. The practice did not keep a log of all safety incidents or carry out an analysis of the significant events on an annual basis.
There were arrangements in place to safeguard adults and children, but staff had not completed recent safeguarding training.
Arrangements were in place to keep medicines safe.
The areas where the provider must make improvements are:
The provider must ensure recruitment arrangements include all necessary employment checks for all staff.
Arrangements for ensuring all staff, including the clinicians, received appropriate support, supervision and appraisal must be reviewed.
The areas where the provider should make improvements are:
All staff should undertake vulnerable adult safeguarding training and the practice lead for safeguarding should complete Mental Capacity Act 2005 training.
All clinicians should ensure that at risk children who fail to attend hospital appointments are followed up by the practice.
Records to show that all equipment has been maintained, tested, serviced and calibrated should be available for inspection.
Infection control training should be completed for the practice infection control lead.
The provider should monitor the quality of service patients receive by having a robust system of clinical audits in place. The provider should consider how the results of these can be used to monitor and improve patients outcomes.
Regular meetings should take place with the local health visiting service to review and update information held about children and vulnerable families with safeguarding risks.
The staffing arrangements should be reviewed to ensure that patients can access a GP on a daily basis.
Minutes should be taken for staff meetings.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice