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The Waterfield Practice Good

Inspection Summary

Overall summary & rating


Updated 27 April 2020

We carried out an announced comprehensive inspection at The Waterfield Practice on 4 March 2020 to follow up on concerns and breaches of regulation identified at our last inspection in February 2019.

At our last inspection (February 2019) we rated the practice as Requires Improvement overall. Specifically, the practice was rated Requires Improvement for providing Safe and Well led services and Good for providing Effective, Caring and Responsive services. We issued requirement notices for regulation 12: Safe care and treatment and regulation 17: Good governance.

At this inspection in March 2020, we found that the provider had satisfactorily addressed these areas, however we identified new areas of concern.

We based our judgement of the quality of care at this service is 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 and good for all population groups. Specifically, we have rated the provider as Requires improvement for Safe services and Good for Effective, Caring, Responsive and Well led services.

We rated the practice as Requires improvement for providing Safe services because:

  • Non-medical prescribers did not receive formal clinical supervision in line with the practice’s own policy. There had been no audits of their consultations or prescribing.
  • Blank prescription stationery had been securely stored but had not been effectively tracked throughout the practice.
  • A fire risk assessment carried out in January 2019 had not had risks actioned for the branch site risk, in regard to fire marshal training or carrying out a fire drill.

We rated the practice as Good for providing Effective, Caring, responsive and Well led services because:

  • Patients received effective care and treatment that met their needs.
  • Staff training oversight had improved and the practice maintained training records for all staff.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The practice had reviewed their governance arrangements following the last inspection and had recruited a quality lead to oversee systems and processes.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Please see the specific details on action required at the end of this report.

In addition, the provider should:

  • Improve disclosure and barring service risk assessments to include the types of risks being measured against.
  • Improve oversight of all new staff recruitment to ensure the practice recruitment process is followed.

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 areas


Requires improvement








Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable