We carried out a review of the data available to us about The Charnwood 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 The Charnwood Practice, you can give feedback on this service.
We carried out an unannounced focused inspection on 28 June 2016 to follow up concerns we found at The Charnwood Practice on 10 February 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
The significant event policy had been reviewed to ensure the process to identify and investigate incidents and significants events was robust.
A safety alert log recorded all safety and medicine alerts and whether it was applicable to the practice.
The practice had devised a list of minimum content for a doctors’ bag and ensured processes were in place to review the contents of a bag and equipment was calibrated.
A defibrillator had been purchased by the practice following completion of a risk assessment.
A risk assessment had been completed to review the appropriate emergency medicines required to stock on the premises.
The practice had developed the training matrix to add the appraisal and revalidation dates for GPs and nurses.
An audit plan had been developed to ensure the findings from clinical audits were reviewed and re-audited.
The practice had signed up for NICE guidelines for primary care to be sent directly to all GPs and nurses and ensured they were discussed at the clinical meetings.
The governance process had been strengthened to ensure all risks had been identified, reviewed and actions taken to mitigate risk.
The complaints process had been strengthened to ensure themes and trends could be identified, including informal complaints.
We carried out an unannounced focused inspection on 28 June 2016 to follow up concerns we found at The Charnwood Practice on 10 February 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
The significant event policy had been reviewed to ensure the process to identify and investigate incidents and significants events was robust.
A safety alert log recorded all safety and medicine alerts and whether it was applicable to the practice.
The practice had devised a list of minimum content for a doctors’ bag and ensured processes were in place to review the contents of a bag and equipment was calibrated.
A defibrillator had been purchased by the practice following completion of a risk assessment.
A risk assessment had been completed to review the appropriate emergency medicines required to stock on the premises.
The practice had developed the training matrix to add the appraisal and revalidation dates for GPs and nurses.
An audit plan had been developed to ensure the findings from clinical audits were reviewed and re-audited.
The practice had signed up for NICE guidelines for primary care to be sent directly to all GPs and nurses and ensured they were discussed at the clinical meetings.
The governance process had been strengthened to ensure all risks had been identified, reviewed and actions taken to mitigate risk.
The complaints process had been strengthened to ensure themes and trends could be identified, including informal complaints.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at The Charnwood Practice on 10 February 2016. Overall, the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
There was a detailed policy and system in place for reporting and recording significant events. However, the practice told us about an incident which we highlighted was a significant event and had not been reported as such.
There was a nominated safeguarding lead and all staff were aware of their responsibilities to keep patients safe and safeguarded from abuse.
The practice maintained appropriate standards of cleanliness and hygiene and the premises were visibly clean and tidy.
We found out of date swabs, blood bottles and urine sticks in one doctors bag, as well as a piece of equipment that had not been calibrated since 2008. The practice took immediate action to remove and replace these.
Risks to patients were generally assessed and managed. However, the practice had not considered risk assessments for the need of a defibrillator on site, or assessed what emergency medicines were appropriate.
There was a comprehensive business continuity plan in place and was available off site as well as at the practice.
Clinical templates and care plans supported best practice guidance
Staff had the skills, knowledge and experience to deliver effective care and treatment.
There was evidence of appraisals and personal development plans for all staff. Although, the practice management team did not record when a GPs’ appraisal or revalidation was due.
There were limited clinical audits undertaken to demonstrate quality improvement in performance to improve patient outcomes.
Multidisciplinary working was taking place but was generally informal and record keeping was limited or absent.
The practice monitored data provided by the CCG in regards to hospital attendances, admissions and outpatient attendances.
Carers were identified at the point of registration. However, at the time of our inspection the practice were unable to provide how many carers had been identified.
Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified. For example, a sexual health and contraception clinic was offered at the practice to registered and non-registered patients.
Most patients said they found it easy to make an appointment with a named GP and there was continuity of care.
The practice had good facilities and was well equipped to treat patients and meet their needs.
The practice had a vision and strategy to deliver high quality care and promote good outcomes for patients but the systems in place to enable good governance needed strengthening to achieve this aim.
The practice had a number of policies and procedures to govern activity and held regular governance meetings.
There was an overarching governance framework, which supported the delivery of the strategy and good quality care. However, some systems were not effective and required improvement.
The provider was aware of and complied with the requirements of the Duty of Candour.
The practice sought feedback from staff and patients, which it acted on. The patient participation group (PPG) was active and the practice acted on feedback from the PPG. However, they did not identify trends from complaints received or recorded any lessons learnt as a result of these to improve the quality of care.
The areas where the provider must make improvements are:
Ensure governance arrangements in place identify, assess and mitigate against risk. For example:
Carry out clinical audits and repeat them to ensure improvements in patient outcomes are made.
Ensure all significant events are identified, recorded and investigated.
Have systems in place to demonstrate safety alerts have been actioned and NICE guidelines discussed and disseminated as appropriate.
Have systems to check doctors have been revalidated.
Identify trends from complaints received and any lessons learnt as a result of these to improve the quality of care.
Ensure the need for emergency medicines has been assessed.
A system is in place to check items kept in doctor’s bags, including equipment and single use items.
Ensure the decision not to hve a defibrillator has been assessed.
Chief Inspector of General Practice
The provider had audits in place for infection prevention and control systems, cleanliness of premises and monitoring storage of clinical equipment. There were systems in place to ensure the practice was kept clean and the standard of the cleanliness was regularly monitored. We found the provider had considered any risks within the practice and was addressing these.