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Inspection Summary


Overall summary & rating

Good

Updated 28 June 2017

Letter from the Chief Inspector of General Practice

We had carried out an announced comprehensive inspection of Malvern Health Centre on 19 January 2016. As a result of our inspection the practice was rated as good overall but required improvement for providing effective services.

During the last inspection we identified a breach of regulation around effective care and treatment. The areas we identified the provider must improve included:

  • Review the clinical audit programme to ensure continuous improvements are made to patient care.

  • Ensure that audits are dated and include a timescale for when they will be re-audited to ensure improvements made in patient care have been sustained.

Following the inspection the practice sent us an action plan detailing the actions they were going to take to improve.

We carried out a focused desk-based review of Malvern Health Centre on 23 February 2017 to check that the provider had made improvements in line with our recommendations and to ensure regulations were now being met. This report only covers our findings in relation to those requirements. The full comprehensive report for the January 2016 inspection can be found by selecting the ‘all reports’ link for Malvern Health Centre on our website at www.cqc.org.uk.

The practice is now rated as good for the provision of effective services.

As part of our focused desk-based review the management team provided evidence to demonstrate that:

  • The audit policy had been revised and a clinical audit template had been implemented to ensure continuous improvement to patient care was monitored, evaluated and maintained.

  • We received copies of audits to show that improvements had been made. The evidence confirmed that audits were dated and included timescales for re-audit to ensure improvements made in patient care had been sustained.

We were satisfied that the practice had made the required improvements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 28 June 2017

Effective

Good

Updated 28 June 2017

The practice is rated as good for providing effective services.

  • The provider had revised their system of clinical audit to ensure clinical risks to patients were identified, assessed and minimised.
  • The provider ensured that audits were dated and included a timescale for when they were re-audited to ensure improvements made in patient care had been sustained.

Caring

Good

Updated 28 June 2017

Responsive

Good

Updated 28 June 2017

Well-led

Good

Updated 28 June 2017

Checks on specific services

People with long term conditions

Good

Updated 3 March 2016

The practice is rated good for people with long term cnditions. Practice nurses and GPs were involved in the management of patients with chronic diseases and those at risk of hospital admission. All of these patients had regular health reviews with either the GP and/or the nurse to check their health and medication. Patients with complex needs had care plans in place and these were reviewed regularly. Patients were able to carry out self-blood pressure monitoring at home. They were also provided with anti-coagulation monitoring in their own home if they could not access the practice.

Families, children and young people

Good

Updated 3 March 2016

The practice is rated good for the care of families, children and young people. 

There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk. A health visitor was invited to the regular multidisciplinary meetings to discuss any safeguarding issues as well as those children who had long term conditions. There were extended opening hours with appointments starting at 7.40am each day. Appointments were also available from 9am until12pm one in every four Saturdays. Patients could hold a telephone conversation with a GP to receive advice. Children were given same day appointments and there was emphasis on children receiving their required vaccinations.

Older people

Good

Updated 3 March 2016

The practice is rated good for the care of older people. 

The practice offered personalised care to meet the needs of the older people in its population and home visits were carried out all clinical staff to those who were unable to access the practice. Rapid access appointments were provided for those with enhanced or complex needs. The practice had regular contact with district nurses and other professionals in meetings to discuss any concerns or changes that were needed to patient care. Older patients were offered annual health checks and where necessary, care, treatment and support arrangements were implemented.

Working age people (including those recently retired and students)

Good

Updated 3 March 2016

The practice is rated good for the care of working-age people (including those recently retired and students). 

The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible. The practice was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs of this age group. GPs liaised with and sought advice from other health and social care professionals to promote provision of appropriate care. Extended hours were provided to assist patient’s ability to attend the practice outside of working hours.

People experiencing poor mental health (including people with dementia)

Good

Updated 3 March 2016

The practice is rated good for the care of people experiencing poor mental health (including people with dementia). Staff were trained to recognise metal health presentations and carry out comprehensive assessments. Practice staff regularly worked with multidisciplinary teams in the case management of patients who experienced poor mental health. Patients who had dementia were included in these meetings and the minutes we saw evidenced this. Clinical staff carried out care planning for patients with dementia and those experiencing mental health illness. Referral mechanisms were in place for when staff identified deterioration in patient’s mental health.

People whose circumstances may make them vulnerable

Good

Updated 3 March 2016

The practice is rated good for the care of people whose circumstances may make them vulnerable. The practice held a register of patients living in vulnerable circumstances including those with a learning disability. Clinical staff carried out annual health checks for patients with a learning disability and longer appointments. Staff knew how to recognise signs of abuse, they kept a register and the computer system included alerts of those patients who were considered to be at risk. Staff were aware of their responsibilities regarding the actions they should take if they had concerns and we saw evidence of this.