The Care Quality Commission
  • Doctor
  • GP practice

Meltham Group Practice

Overall: Good read more about inspection ratings

1 The Cobbles, Meltham, Holmfirth, West Yorkshire, HD9 5QQ (01484) 347620

Provided and run by:
Meltham Group Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Meltham Group Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Meltham Group Practice, you can give feedback on this service.

15 June 2019

During an annual regulatory review

We reviewed the information available to us about Meltham Group Practice on 15 June 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.

19 April 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the surgery of Meltham Group Practice on 10 August 2016. Overall the practice was rated as good; however a breach of the legal requirements was found which resulted in the practice being as rated as requires improvement for providing safe services.

Following on from the inspection the practice provided us with an action plan detailing evidence of the actions they had taken to meet the standards relating to providing safe services.

We undertook a desk based review on 13 April 2017 and visited the practice on 19 April 2017. This was to review in detail the information the practice had sent to us and to confirm that the practice were now meeting the relevant standards of care.

A full comprehensive report which followed the inspection on 10 August 2016 can be found by selecting ‘all reports’ link for Meltham Group Practice on our website at www.cqc.org.uk.

The practice is now rated as good for providing safe services.

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

  • Patients Specific Directions (PSDs) had been developed and were in use for a range of immunisations and specific treatments

  • The Health Care Assistant had attended the required vaccination competency update since the last inspection

  • The cleaning regime and recording of completion of tasks had been reviewed and implemented.

  • The risk assessments for the control of substances hazardous to health (COSHH) had been undertaken and documented.

  • The practice had reviewed the cleaning of curtains and now were using disposable curtains, which were changed every six months.

  • The serial numbers of blank prescriptions were logged and tracked in line with best practice guidance.

  • The recruitment of staff had been reviewed and there was evidence that since the previous inspection two references and proof of identity had been taken prior to commencing employment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Meltham Group Practice on 10 August 2016. 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. We saw evidence that the team held regular meetings to discuss significant events and any lessons that were learnt as a result of the investigation.
  • 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.
  • Patients said they were treated with care, kindness 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.
  • There was good access to clinicians and patients said they found it generally easy to make an appointment. There was continuity of care and if urgent care was needed patients were seen on the same day as requested.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Safeguarding was a priority for the practice and we saw evidence that best practice was followed. Staff knew how to recognise signs of abuse in vulnerable adults and children and any safeguarding concerns were discussed at a multi-disciplinary meeting each week.
  • We saw that reception staff were acting as chaperones without a Disclosure and Barring Service check (DBS) or an appropriate assessment of the risks. (DBS checks identify 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). The day after our visit the practice forwarded a completed risk assessment to support this intervention.
  • The practice could not evidence any patient specific directions (PSD). A PSD is a written instruction, signed by a doctor for medicines to be supplied and/or administered to a named patient after the prescriber has assessed the patient on an individual basis.
  • At the time of our inspection the practice had ceased to record the distribution of pre-printed prescription form stock within the practice.
  • There was a clear leadership structure, staff were aware of their roles and responsibilities and told us that the GPs were accessible and supportive.
  • Not all necessary employment checks had been undertaken prior to employment, for example references or proof of identity.
  • The practice proactively sought feedback from staff and patients and the Patient Reference Group (PRG), which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour. (The duty of Candour is a set of specific legal requirements that providers of services must follow when things go wrong with care and treatment).

We saw one area of outstanding practice:

We saw evidence of good outcomes and high quality dementia care in the practice. Opportunistic screening took place. Further assessments were undertaken by a GP with specialist qualifications in this area. We saw that a comprehensive template was used to support this. The practice had a nominated Dementia champion and we saw that staff had been trained as ‘dementia friends’.

The areas where the provider must make improvement are:

The provider must ensure that they can evidence written patient specific directions (PSD). The provider must ensure that PSDs are developed to enable health care assistants to safely administer vaccinations to named patients after specific training.

The areas where the provider should make improvement are:

The practice should review its cleaning regimes, including the risk assessments for the control of substances hazardous to health (COSHH). The practice should also review the cleaning regime of the fabric curtains in the practice and follow best practice.

The practice should review their systems for the logging and tracking serial numbers of blank prescriptions, in line with best practice guidance.

The provider should review its procedures with regards to recruitment and be able to evidence appropriate references for staff and proof of their identity.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice