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Inspection carried out on 04/07/2019

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

We carried out an announced focussed inspection at Rainbow Medical Centre on 4 July 2019 as part of our inspection programme.

The inspection of this service followed our annual review of the information available to us. This inspection looked at the following key questions:

Effective and

Well-led.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall.

The practice was rated as requires improvement for providing effective services because:

The practice did not have robust systems in place to ensure urgent referrals were readily monitored and able to confirm that timely remedial action had been taken if there was a delay.

This area affected all population groups so we rated all population groups requires improvement.

We rated the practice as good for providing safe, caring, responsive and well-led services

We found that:

  • The practice provided in house care in a way that kept patients safe and protected them from avoidable harm.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice generally organised and delivered services to meet patients’ needs. The provider had increased the type of appointments available so that patients could access care and treatment at the practice in a timely way.
  • The way the practice was led and managed promoted the delivery of person-centre care.
  • The practice had developed a process to ensure all clinicians were using up to date agreed templates. This promoted consistency in coding illnesses which would in turn improve the information used to audit outcomes for patients.
  • The agreed templates system also improved working practices for new members of staff, clinical trainees and locums. The templates promoted patient safety through alerts and best practice guidance pop-ups which provided suggestions for referrals.
  • The practice had extended their hours of opening to deliver additional urgent and routine GP appointments.
  • Patient demand was monitored and opening times changed to meet the demands identified. This had led to improved patient satisfaction and less stress for staff working at the practice.

The area where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care relating to ensuring patients receive the correct treatment and care in a timely manner.

The area where the provider should make improvements are:

  • Develop a written business plan which includes reflection on previous performance, formalises the vision and provides a clear strategy including action plans, risk assessments, targets and review dates aligned to the aims and vision of the practice.
  • Formalise systems to review the quality of care provided and staff performance in relation to adhering to quality assurance processes, such as policies and procedures or best practice guidance.
  • Develop audit and quality improvement plans based on priorities identified through available data.
  • Review the aims and objectives of audits to ensure the process will review the priorities relevant to the subject. For example, the practice completed an audit of ‘death and dying’ but the Gold Standard Framework for end-of -life care was not used to inform the outcomes which were reviewed.

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

Inspection carried out on 10 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Rainbow Medical Centre, St Helen’s on 10 March 2015. Overall the practice is rated as good.

Rainbow Medical Centre provided effective, responsive care that was well led and addressed the needs of the population it served. The service was safe, caring and compassionate. It was also good for providing services for all of the population groups.

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

  • Systems were in place to ensure incidents and significant events were identified, investigated and reported. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Lessons learnt were disseminated to staff. Infection risks and medicines were managed safely.

  • Patients’ needs were assessed and care was planned and delivered in line with current legislation and guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned. Patients experienced outcomes that were in line with or above the national average. For example, care plans were in place for vulnerable and older patients to reduce unplanned admissions to hospital and annual reviews for people with long term conditions were carried out.

  • Patients spoke highly of the practice. They said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.

  • The practice provided good care to its population that was responsive to their health needs. Patients were listened to and feedback was acted upon. Complaints were managed appropriately. Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.

  • The practice monitored, evaluated and improved services. Staff enjoyed working for the practice and felt well supported and valued. 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.

There were areas of practice where the provider needs to make improvements.

The provider should:

  • Ensure a suitable system is in place for identifying and managing local risks associated with the building in which the practice was based. For example general, environmental and health and safety risk assessments, including the risks presented by legionella. (A bacterium found in the environment which can contaminate water systems in buildings).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice