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Archived: Mirfield Health Centre Good

The provider of this service changed - see new profile


Inspection carried out on 14 February 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (The practice was previously inspected on 7 July 2016. On that occasion the practice received a rating of Good overall, with a rating of Outstanding for providing effective services).

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Mirfield Health Centre on 14 February 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had clear governance policies and protocols which were accessible to all staff.
  • There were well developed systems to identify and manage risk within the practice. Processes for recognising, reporting and learning from incidents were embedded.
  • The practice routinely reviewed the effectiveness and appropriateness of the care provided. Care and treatment was delivered in line with current evidence based guidance. The practice benchmarked performance against other practices in the locality.
  • The practice had responded to patient survey results relating to delays in accessing appointments. They had made improvements and changes to their systems; and provided evidence which showed that abandoned calls and call wait times had been significantly reduced; the number of available appointments had significantly increased and waiting times to be seen had reduced in the period between January 2017 and January 2018.
  • We observed staff treating patients with kindness, compassion and good humour. Patients we spoke with confirmed this impression.
  • Staff were encouraged and supported to develop within their role. Staff at all levels were able to access role development opportunities.
  • The practice engaged in a positive way with the local community. Sponsorship was provided for a local girls’ football team, there was reciprocal engagement with the local primary school, and outreach support was provided to a nearby hostel for homeless people.

The areas where the provider should make improvements are:

  • Improve systems for collating and recording informal verbal complaints and compliments.
  • Improve record keeping associated with the cleaning of equipment.
  • Continue to monitor, review and take steps to improve patient satisfaction in accessing appointments and receiving care.
  • Review their arrangements for the identification of carers to assure themselves that they are identifying them effectively, and are able to offer them the appropriate support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 7 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mirfield Health Centre on 7 July 2016. The practice has been rated as outstanding for effectiveness and for the long-term condition population group. Overall the practice is rated as good.

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. Lessons were shared to make sure action was taken to improve safety in the practice.
  • Risks to patients were assessed and well managed.
  • Data showed that the practice was performing highly when compared to practices nationally.
  • 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.
  • The continuing development of staff skills, competence and knowledge was recognised as integral to ensuring high-quality care and staff were proactively supported to acquire new skills.
  • 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 told us that is was sometimes difficult to get through on the phone at busy times but it had improved over the preceding few months. The practice had installed three additional phone lines and additional reception staff to improve access for patients. Urgent appointments were 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.

We saw areas of outstanding practice:

  • All staff were actively engaged in activities to monitor and improve quality and outcomes. The nursing team worked together to manage long term conditions and carried out reviews of patients in their own home where necessary. The practice changed the process to recall patients for their review which significanty increased uptake and performance. Data showed that the practice was performing highly when compared to practices locally and nationally.
  • The practice were aware that the prevalence of chronic obstructive pulmonary disease (COPD) was lower than expected in 2014. They audited COPD diagnosis and outcomes and introduced in-house screening and diagnostic spirometry. As a result, COPD was diagnosed in over 100 additional patients. The practice demonstrated a 12% improvement on the number of patients with COPD who had their diagnosis confirmed by post bronchodilator spirometry.
  • Staff worked together in a targeted and proactive approach to improve the patient uptake of flu vaccinations. The practice received a letter of congratulations for achieving the national target of over 75% for the first time in 2014/15. This was an increase of 10% from 2013/14.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During a check to make sure that the improvements required had been made

On our previous inspection we found that the provider did not follow their recruitment and selection policy, this meant they could not be assured of the good character of their employees.

We have received documentation which showed that the provider now operates effective recruitment and selection procedures in order to ensure that persons who were employed for the purposes of carrying on a regulated activity were of good character. Regulation 21 (a) (i)

Inspection carried out on 13 February and 3 March 2014

During a routine inspection

As part of our inspection we spoke with five people who used the service and nine staff members. This included a doctor, nurse practitioner/practice nurses, practice manager, administration staff and reception staff. We inspected a second day, as the provider had not provided information requested following the first day of inspection.

We found appointments were provided by a multidisciplinary team of staff and these included, doctors, nurse practitioners and practice nurses.

People experienced mixed views on how easy it was to get an appointment and whether they were able to book in advance.

The practice respected people�s choices and promoted the health and wellbeing of people who used the service.

Staff were aware of the safeguarding procedures and procedures were in place for them to respond appropriately to allegation of abuse.

The provider had not undertaken appropriate checks prior to recruiting staff. We have judged that this has a minor impact on people who use the service, and have told the provider to take action.

The practice had a complaints procedure and staff were aware of the procedure to follow should someone wish to complain.