Archived: Drs Marshall & Whitlow Also known as Newark Road Surgery

Updated 22 September 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 6 January 2016. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12, 13, 17 and 18.

We undertook a focussed inspection on 26 July 2016 and 2nd August 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements. You can read the last comprehensive inspection report from January 2016 by selecting the ‘all reports’ link for Newark Road Surgery on our website at www.cqc.co.uk

• We found that an improved significant event system had been put in place. The policy and reporting form had been updated. The practice had had eight significant events since the last inspection and we looked at them all. We found the updated system still required some improvement to ensure that the investigations were detailed and actions were identified and implemented.

• The practice now had a system in place to ensure that patients were safeguarded from abuse and improper treatment

• We found that in most cases learning from significant events and complaints was shared with staff but themes and trends still needed to be identified and an action plan put in place where appropriate.

• Risks to patients were now assessed and most were well managed.

• Action had been taken to address identified concerns with infection prevention and control practice.

• A fire drill had taken place and fire alarm testing was carried out regularly

• The practice had embedded a process to ensure emergency equipment and medicines were checked as per the practice protocol.

• Staff had received an annual appraisal.

• We found the nurse prescriber had received clinical supervision

• There was system in place for the recall of patients with long term conditions and undertake annual reviews.

• The practice had a new system for the identification of carers.

• The practice had commenced a more formalised process for the recording of minutes of meetings but the clinical meeting minutes still required more detail.

• Staff had appropriate policies and guidance in place to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice and which identify the responsible person. For example, legionella, cold chain, checking of emergency equipment and medicines.

The areas where the provider should make improvements are:

• Continue to embed the updated system for significant events and identification of carers.

• Identify themes and trends from significant events and complaints and take action where appropriate.

• Complete the work required to ensure staff and patients are safe. For example, in regard to fire safety.

• Ensure the reviews for patients with a learning disability take place.

• Ensure all staff files have the appropriate recruitment documents and files are in order as per the practice policy.

• Complete the appraisal process ensuring the notes of the discussions that had taken place are typed and added to the staff file.

• Complete the process for reorganising all staff files.

• Include safety alerts for discussion at meetings and ensure minutes are detailed.

• Continue to assess and monitor the quality and safety of the service provision by completing a full patient survey.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 22 September 2016

We carried out an announced comprehensive inspection of the practice on 6 January 2016. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12, 13, 17 and 18.

We undertook a focussed inspection on 26 July 2016 and 2 August 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements. You can read the last comprehensive inspection report from the January 2016 by selecting the ‘all reports’ link for Newark Road Surgery on our website at www.cqc.co.uk

Following this most recent inspection we found that overall the practice was now rated as good and significant improvements had been made specifically, the ratings for providing a safe, effective and well led service. These rating applied to everyone using the practice, including this population group

The practice is now rated as good for the care of people with long-term conditions.

Updated 22 September 2016

We carried out an announced comprehensive inspection of the practice on 6 January 2016. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12, 13, 17 and 18.

We undertook a focussed inspection on 26 July 2016 and 2 August 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements. You can read the last comprehensive inspection report from the January 2016 by selecting the ‘all reports’ link for Newark Road Surgery on our website at www.cqc.co.uk

Following this most recent inspection we found that overall the practice was now rated as good and significant improvements had been made specifically, the ratings for providing a safe, effective and well led service. These rating applied to everyone using the practice, including this population group

The practice is now rated as good for the care of families, children and young people.

Updated 22 September 2016

We carried out an announced comprehensive inspection of the practice on 6 January 2016. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12, 13, 17 and 18.

We undertook a focussed inspection on 26 July 2016 and 2 August 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements. You can read the last comprehensive inspection report from the January 2016 by selecting the ‘all reports’ link for Newark Road Surgery on our website at www.cqc.co.uk

Following this most recent inspection we found that overall the practice was now rated as good and significant improvements had been made specifically, the ratings for providing a safe, effective and well led service. These rating applied to everyone using the practice, including this population group

 The practice is now rated as good for the care of older people.

Updated 22 September 2016

We carried out an announced comprehensive inspection of the practice on 6 January 2016. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12, 13, 17 and 18.

We undertook a focussed inspection on 26 July 2016 and 2 August 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements. You can read the last comprehensive inspection report from the January 2016 by selecting the ‘all reports’ link for Newark Road Surgery on our website at www.cqc.co.uk

Following this most recent inspection we found that overall the practice was now rated as good and significant improvements had been made specifically, the ratings for providing a safe, effective and well led service. These rating applied to everyone using the practice, including this population group

The practice is now rated as good for the care of working-age people (including those recently retired and students).

Updated 22 September 2016

We carried out an announced comprehensive inspection of the practice on 6 January 2016. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12, 13, 17 and 18.

We undertook a focussed inspection on 26 July 2016 and 2 August 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements. You can read the last comprehensive inspection report from the January 2016 by selecting the ‘all reports’ link for Newark Road Surgery on our website at www.cqc.co.uk

Following this most recent inspection we found that overall the practice was now rated as good and significant improvements had been made specifically, the ratings for providing a safe, effective and well led service. These rating applied to everyone using the practice, including this population group

The practice is now rated as good for the care of people experiencing poor mental health (including people with dementia).

Updated 22 September 2016

We carried out an announced comprehensive inspection of the practice on 6 January 2016. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12, 13, 17 and 18.

We undertook a focussed inspection on 26 July 2016 and 2 August 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements. You can read the last comprehensive inspection report from the January 2016 by selecting the ‘all reports’ link for Newark Road Surgery on our website at www.cqc.co.uk

Following this most recent inspection we found that overall the practice was now rated as good and significant improvements had been made specifically, the ratings for providing a safe, effective and well led service. These rating applied to everyone using the practice, including this population group

The practice is now rated as good for the care of people whose circumstances may make them vulnerable.