Background to this inspection
Updated
23 January 2020
The Northolme Practice operates across two sites. The main site (Kos Clinic) is located at Hipperholme Surgery, Roylands Street, Hipperholme, Halifax HX3 8AF. The branch site is located at Northowram Green, Northowram, Halifax HX3 7JE, approximately two miles from the main site.
Patients are able to access appointments at either of the two sites. Clinical staff work across both sites, whilst in the main non-clinical staff are based at one or other site for their working week. We only visited the Northowram site during our inspection.
The practice is registered with the Care Quality Commission to carry out the following regulated activities:
- Diagnostic and screening procedures
- Family planning
- Maternity and midwifery services
- Surgical procedures
- Treatment of disease, disorder or injury
There are currently 15,465 patients registered at the practice. The practice provides General Medical Services (GMS) under a locally agreed contract with NHS England.
The Public Health National General Practice Profile shows that around 3% of the practice population are of black or other non-white ethnic origin. The level of deprivation within the practice population is rated as nine, on a scale of one to ten. Level one represents the highest levels of deprivation, and level ten the lowest.
The age/sex distribution of the practice is largely in line with national averages. The average life expectancy for patients at the practice is 80 years for men and 84 years for women, compared with the national average of 79 years and 83 years respectively.
The clinical team is made up of six GP partners, four male and two female; four nurse practitioners, three practice nurses, one treatment room nurse and one health care assistant, all of whom are female.
Supporting the clinical team is a practice manager, clinical information manager, IT manager, practice administrator, administrative team manager, two reception managers and a range of administrative, secretarial and reception staff.
The practice is a training practice, providing training for fully qualified doctors wishing to specialise in general practice. At the time of our visit four such trainees were in post, two female and two male.
The practice is part of the Lower Valley Primary Care Network (PCN). One of the partners acts as clinical director for the PCN.
Practice opening times are:
Hipperholme site: Monday to Friday 7.30am to 6.30pm,
Northowram site: Monday to Friday 7.30am to 6pm.
Patients are also able to access evening and weekend appointments at a nearby hub as part of the local extended access service.
Both sites are single storey buildings. Limited parking is available on site, with dedicated disabled parking space at both locations.
Out of hours care is provided by Local Care Direct which is accessed by calling the surgery telephone number or by calling the NHS 111 service.
When we returned to the practice, we checked and saw that the ratings from the previous inspection were displayed as required in the practice.
Updated
23 January 2020
We carried out an announced comprehensive inspection at The Northolme Practice on 9 January 2019. The overall rating for the practice was good, with requires improvement for providing safe services.
The full comprehensive report on the January 2019 inspection can be found by selecting the ‘all reports’ link for The Northolme Practice on our website at .
This inspection was an announced focused inspection, carried out on 8 January 2020 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified at our previous inspection on 9 January 2019.
This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is rated as good. The key question of are services safe is now also rated as good.
At our previous inspection on 9 January 2019 we rated the practice as requires improvement for providing safe services as disclosure and barring service (DBS) checks had not been carried out for staff performing chaperone duties, and risk assessments to this effect had not been completed. In addition, infection prevention and control processes were not sufficiently thorough; actions from premises risk assessments had not been carried out and window blind cords were not secured in line with safety regulations in all cases. We also found that systems for logging and tracking blank prescriptions were not sufficiently thorough, and staff vaccination status was not reviewed in line with department of health guidelines.
At this inspection we found that these issues had been addressed, and additional improvements had also been implemented.
Our key findings were as follows:
- The provider had reviewed their approach to DBS checks. These were completed for all staff, including those undertaking chaperone duties.
- Infection prevention and control processes were thoroughly implemented and understood by all.
- Actions from premises risk assessments had been completed.
- Systems for logging and tracking blank prescriptions had been improved.
- Window blind cord loops were appropriately secured in line with legal requirements.
- Staff vaccination status had been reviewed and staff signposted to receive any outstanding immunisations.
- Appraisals for all staff, including non-clinical staff had been scheduled within timescales.
- Systems for dissemination of clinical updates were improved and embedded.
- Systems for identifying vulnerable adults on clinical records had been developed and were being rolled out.
The areas where the provider should make improvements are:
- Update their recruitment policy to accurately reflect the decisions made in relation to staff DBS checks.
- Develop formal written guidance to assist non-clinical staff in identifying and appropriately signposting patients with urgent or less urgent needs.
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