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Cromwell Medical Centre Good Also known as Cromwell and Wormley Medical Centres

Reports


Inspection carried out on 20/10/2016

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

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Cromwell Medical Centre on 20 October 2016. This was to check that improvements had been made following the breaches of legal requirements we identified from our comprehensive inspection carried out on 21 April 2016. During our inspection in April 2016 we identified regulatory breaches in the safe care and treatment, staffing and governance at the practice.

This report only covers our findings in relation to the areas requiring improvement as identified on inspection in April 2016. You can read the report from this comprehensive inspection, by selecting the 'all reports' link for Cromwell Medical Centre on our website at www.cqc.org.uk. The areas identified as requiring improvement during our inspection in April 2016 were as follows:

  • Maintain accurate records of investigations of safety incidents and complaints.
  • Ensure an appropriate system is in place for the safe use and management of medicines including a system for tracking blank prescription forms and pads, having valid and approved Patient Group Directions (PGDs) and Patient Specific Direction (PSDs).
  • Carry out a risk assessment to ensure the appropriateness of emergency medicines stocked.
  • Ensure that systems designed to assess the risk of and to prevent, detect and control the spread of infection are fully implemented.
  • Ensure that all applicable staff receive a criminal records check and that the required information is available in respect of the relevant persons employed.
  • Ensure that all staff employed are supported, receive the appropriate supervision and complete the essential training relevant to their roles and accurate records are kept in respect of the relevant persons employed.
  • Make available a business continuity plan.
  • Ensure a record of meetings held within the practice is kept.
  • Review and date practice specific policies so these are reflective of current legislation and guidance.
  • Maintain an oversight of the governance system in place to monitor the quality of the service.

Our key findings on this focused inspection across the areas we inspected were as follows:

  • The practice had an effective system in place for reporting and recording significant events, including handling complaints and concerns.
  • The practice had appropriate systems in place for the safe use and management of medicines, including emergency medicines and prescriptions. The practice had up-to-date Patient Group Directions (PGD’s) and Patient Specific Directions (PSD’s) in place.
  • Systems and processes were in place to assess the risk of and to detect, prevent and control the spread of infection. For example, the practice had completed an infection control audit and had taken action to address improvements identified as a result.
  • The practice had risk assessed the roles of all non-clinical staff and appropropriate checks had been undertaken through the Disclosure and Barring Service (DBS) check where applicable.
  • A process was in place to ensure regular staff appraisals and all staff had completed essential training relevant to their roles.
  • Practice policies were specific and up-to-date and reflected current legislation and guidance.
  • Steps had been taken to review and make improvements to the disabled patient toilet facilities. For example, an emergency call bell had been installed.
  • The practice had a business continuity plan in place.
  • Records were maintained of practice meetings and the practice had an overarching governance system in place to monitor the quality of services provided.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 21 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cromwell Medical Centre on 21 April 2016. Overall the practice is rated as requires improvement.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not documented other than a summary.
  • Risks to patients were assessed and managed, with the exception of those relating to recruitment checks, infection control, medicine management DBS checks and health and safety.
  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average with the exception of diabetic and hypertension indicators which were below CCG and national averages but the practice was acting to make improvements.
  • Patients said they were treated with compassion, dignity and respect.
  • The January 2016 patient survey results showed that the practice was performing above CCG and national averages in relation to providing a caring and responsive service.
  • Some practice specific policies were available to govern activity, but these were not always reflective of current legislation and guidance and dated.
  • The oversight of the governance system in place to monitor the quality of the service was not sufficient.

The areas where the provider must make improvements are:

  • Maintain accurate records of investigations of safety incidents and complaints.
  • Ensure an appropriate system is in place for the safe use and management of medicines including a system for tracking blank prescription forms and pads, having valid and approved Patient Group Directions (PGDs) and Patient Specific Direction (PSDs).
  • Carry out a risk assessment to ensure the appropriateness of emergency medicines stocked.
  • Ensure that systems designed to assess the risk of and to prevent, detect and control the spread of infection are fully implemented.
  • Ensure that all applicable staff receive a criminal records check and that the required information is available in respect of the relevant persons employed.
  • Ensure that all staff employed are supported, receive the appropriate supervision and complete the essential training relevant to their roles and accurate records are kept in respect of the relevant persons employed.
  • Make available a business continuity plan.
  • Ensure a record of meetings held within the practice is kept.
  • Review and date practice specific policies so these are reflective of current legislation and guidance.
  • Maintain an oversight of the governance system in place to monitor the quality of the service.

The areas where the provider should make improvements are:

  • Make the disabled toilet Equality Act 2010 compliant by providing an emergency call bell.
  • Ensure the premises are maintained in reasonable condition pending plans to transfer to purpose built premises.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice