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Wensum Valley Medical Practice West Earlham Health Centre Good

Inspection Summary


Overall summary & rating

Good

Updated 13 April 2018

This practice is rated as Good overall. At the previous Care Quality Commission (CQC) inspection in July 2017, the practice received an inadequate overall rating and was placed in special measures for a period of six months.

Our announced comprehensive inspection on 18 March 2018 was undertaken to ensure that improvements had been made following our inspections carried out in July 2017.

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 previously carried out an announced comprehensive inspection at Wensum Valley Medical Practice on 12 October 2016. The overall rating for the practice was requires improvement (safe and effective were rated as requires improvement, caring, responsive and well-led all rated as good).

We carried out an announced focused inspection on 18 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection. However, insufficient improvements had been made and we subsequently carried out an announced comprehensive inspection on 24 July 2017 with a follow-up unannounced focused inspection on 31 July 2017 to assess the immediate actions taken. The practice were rated as inadequate overall (inadequate for safe and well led services and requires improvement for caring, effective and responsive services).

We carried out an announced comprehensive inspection at Wensum Valley Medical Practice

on 13 March 2018. This inspection was undertaken following the period of special measures and to confirm that the practice now met the standards in relation to the breaches in regulation (give breaches). Overall, the practice is now rated as good. The practice is no longer in special measures.

The full reports on the July 2017 and October 2016 inspections can be found by selecting the ‘all reports’ link for Wensum Valley Medical Practice on our website at www.cqc.org.uk.

At this inspection we found:

  • The practice showed evidence that they had been responsive to the findings of the previous report and had made significant improvements. The clinical leadership had been improved, all partners had been involved and practice staff we spoke with told us that they had been included in the development of the action plan and had been fully engaged in the changes made. The clinical commissioning group (CCG) had been engaged with and had supported the practice where appropriate. The practice had employed a new practice manager who had been fully in post since September 2017. The practice had also engaged a new partner and full time pharmacist, both of whom commence their posts on 1 April 2018.
  • The practice was clear on the improvements that had been achieved or were in process or being embedded. They had undertaken a significant number of audits to ensure the changes they had made had been effective.
  • The practice was aware of their population needs and the levels of deprivation that affected them. All staff had received training to become a dementia friendly practice.
  • We found the system in place for reporting and recording significant events and complaints had been improved, and embedded. Risk assessments had been undertaken in a systematic and organised way.
  • The practice had implemented a suite of practice specific policies and procedures which staff had read and were using. A new practice intranet system was in place and this was in the process of being fully populated.
  • The system in place to deal with and monitor patient safety alerts had been reviewed and improved, ensuring that patients were appropriately monitored.
  • The process to manage medicines prescribed to patients had been improved. A fully electronic system giving a clear audit trail of changes and clinical oversight had been implemented.
  • An effective system to manage correspondence had been implemented. Clear polices and protocols had been embedded to ensure that GPs saw all correspondence that required a clinical view.
  • A fully electronic system had been introduced to ensure that staff were employed safely and that training requirements were met. We found that all staff had received the training deemed mandatory by the practice.
  • Clinical oversight had been introduced to ensure that home visits were managed safely and in a timely manner.
  • Data from the Quality and Outcomes Framework showed patient outcomes in many areas were mixed with areas above, in line, or below the national averages. Some exception reporting was above the national averages. To ensure this was managed well, the practice had increased clinical oversight into reviewing, improving, and monitoring their performance.
  • The practice had increased the use of SMS messages to patients including where possible in the patients first language.
  • Results from the national GP patient survey, published in July 2017, showed the practice was in line with or below local and national averages for many aspects of care.
  • Since the last inspection the practice had engaged with patients and a patient participation group had been formed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 13 April 2018

Effective

Good

Updated 13 April 2018

Caring

Good

Updated 13 April 2018

Responsive

Good

Updated 13 April 2018

Well-led

Good

Updated 13 April 2018

Checks on specific services

People with long term conditions

Good

Updated 13 April 2018

Families, children and young people

Good

Updated 13 April 2018

Older people

Good

Updated 13 April 2018

Working age people (including those recently retired and students)

Good

Updated 13 April 2018

People experiencing poor mental health (including people with dementia)

Good

Updated 13 April 2018

People whose circumstances may make them vulnerable

Good

Updated 13 April 2018