Northern Moor Medical Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Northern Moor Medical practice on 2/12/2015. Overall the practice is rated as requires improvement.

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

• GPs and staff described a system whereby significant events and near misses were reported by reception and administration staff. However the significant event record book behind reception used in this system had not had an entry completed since 2011.
• Clinical staff used templates to record and write up significant event analyses. When significant events were analysed, investigations were not always thorough enough. Staff were unable to tell us of the outcome of significant event analyses.
• Risks to patients were not comprehensively assessed nor well managed, for example those relating to recruitment checks and managing medical emergencies. The practice did not have a defibrillator on site; despite an incident in September 2014 where the practice identified the need to consider obtaining a defibrillator. There was no risk assessment to demonstrate the decision taken.
• Although some audits had been carried out, we saw limited evidence that audits were driving improvement in performance to improve patient outcomes.
• There were gaps in staff training and training was not well managed.
• Patients said they were treated with compassion, dignity and respect. They said they felt cared for, supported and listened to.
• Urgent appointments were available on the day they were requested.
• The practice had a number of policies and procedures to govern activity, but these were poorly managed. There was duplication, some were overdue a review and not all reflected practice’s protocols.
• The practice had attempted to seek feedback from patients and had a patient participation group.

The areas where the provider must make improvements are:

• Investigate safety incidents and significant events thoroughly and ensure action plans are completed and learning disseminated to staff effectively.

• Ensure a system is in place to manage, assess and mitigate risks to patients, for example those risks around medical emergencies.

• Ensure recruitment arrangements include all necessary employment checks for all staff.

• Ensure there are appropriate policy documents in place to govern activity and that a system is in place to manage these documents.

• Ensure staff receive appropriate support, training and supervision to carry out their role, for example chaperoning, and that this training is managed to ensure its effectiveness.

• Ensure all clinical staff have appropriate medical indemnity insurance as required.

In addition the provider should:

• Ensure the infection prevention and control lead receives specific additional training to maximise the value added to this role.

• Ensure the practice manager has access to an appraisal process to identify training needs and support her in the role.

• Ensure cleaning processes are actively monitored.

• Ensure complainants are signposted to other agencies should they wish to pursue their complaint further as appropriate as part of the formalised response.

Where a practice is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected within six months after the report is published. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice