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Reports


Review carried out on 8 July 2021

During a monthly review of our data

We carried out a review of the data available to us about Malvern Health Centre on 8 July 2021. 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 Malvern Health Centre, you can give feedback on this service.

Review carried out on 19 July 2019

During an annual regulatory review

We reviewed the information available to us about Malvern Health Centre on 19 July 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.

Inspection carried out on 23 February 2017

During a routine inspection

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 carried out on 19 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Malvern Health Centre on 19 January 2016. Overall the practice is rated as good.

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

  • There were systems in place to mitigate safety risks including analysing significant events and safeguarding. The premises were clean and tidy.Systems were in place to ensure vaccines stored appropriately and in date.

  • Recruitment procedures included all relevant checks to protect patients from harm. Systems were in place for safe hygiene practices by staff to protect patients from unnecessary risk of infections.

  • Patients had their needs assessed in line with current guidance and clinical staff had a holistic approach to patient care. Staff promoted health education to empower patients to live healthier lives.

  • Feedback from patients and observations throughout our inspection showed that staff were kind, caring and helpful. They told us they were satisfied with the standards of care.

  • Practice staff worked closely with other organisations and external professionals in planning how services were provided to ensure that they meet people’s needs. People with complex needs had care plans in place that were regularly reviewed.

  • Complaints were dealt with appropriately and honest feedback was provided to the complainant.

  • Staff worked together as a team. There was a clear leadership structure and staff felt supported by management. It was evident that there was a motivated staff team.

However, there was an area of practice where the provider needs to make improvements.

The provider must:

  • 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice