You are here

University Health Service Good

Reports


Review carried out on 28 November 2019

During an annual regulatory review

We reviewed the information available to us about University Health Service on 28 November 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 6 December 2016

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

Letter from the Chief Inspector of General Practice

We carried out a focused inspection of University Health Service on 6 December 2016 to check that action had been taken since our previous inspection in April 2015. At the inspection in April 2015 the practice was rated as good overall. The practice was good for Effective, Caring, Responsive and Well Led services.

However we found that the practice required improvement in the Safe domain due to breaches of regulations relating to safe delivery of services. We found that the practice had not ensured that emergency medicines were available, fit for purpose and within the expiry date.

The practice had not ensured that staff recruitment checks were completed in full and the practice needed to carry out risk assessments to identify those members of staff who required a Disclosure and Barring Services check (this check identifies whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

We inspected the practice on 6 December 2016 to check that they had followed their action plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection of University Health Service on our website at www.cqc.org.uk

Our key findings for this inspection were as follows:

The provider had made improvements:

  • Recruitment arrangements included all necessary employment checks for all staff had been carried out.
  • The practice carried out risk assessments to identify those members of staff who required a Disclosure and Barring Services check.
  • New medicines had been purchased and they were now all within the expiry date. Systems had been put in place to ensure that emergency medicines were regularly checked and recorded.

The practice is now rated good for Safe services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 09/04/2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at University Health Service on 9 April 2015.

Overall the practice is rated as good.

Specifically, we found the practice to be good for providing responsive, caring, well-led and effective services for older people, people with long term conditions, families, children and young people, working age people, people whose circumstances may make them vulnerable and people experiencing poor mental health. It required improvement for providing safe services.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded and addressed but monitoring of learning was poor.
  • Risks to patients were assessed and managed, with the exception of those relating to emergency medicines management and staff recruitment.
  • Information sharing and auditing was informal and records were not always kept.

  • The systems and arrangements for governance were not always in place and so staff may not have all the required information for their roles.
  • 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.
  • There was a clear leadership structure and staff felt supported by management.
  • 90% of respondents to a national patient survey said their overall experience of the practice was good.

  • Quality and outcome framework data for this practice in 2013/14 showed it had met 97.9% of the outcomes. This was higher than the national average of 94.2% for GP practices.

The areas where the provider must make improvements are:

  • Ensure emergency medicines are available, fit for purpose and within the expiry date;
  • Ensure staff recruitment checks are completed in full; and
  • Carry out a risk assessment to identify those who require a DBS.

Action the provider SHOULD take to improve:

  • Identify, manage and monitor effective infection prevention and control systems;
  • Carry out staff appraisals in a timely manner; and
  • Review practice policies to ensure they are up to date.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice