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Inspection Summary


Overall summary & rating

Good

Updated 15 August 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 26 February 2016. A breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us with an action plan to say what they would do to meet legal requirements in relation to:

  • Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed.

We undertook this focused inspection to check that they had followed their action plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Kenmore Medical Centre on our website at www.cqc.org.uk

Our key findings were as follows:

  • The practice had addressed the issues identified during the previous inspection. Disclosure and Barring Service (DBS) checks had been completed for all necessary staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 15 August 2016

The practice is rated as good for providing safe services. The practice had addressed the issues identified during the previous inspection with regard to having satisfactory references and disclosure and barring checks. 

Effective

Good

Updated 15 August 2016

Caring

Good

Updated 15 August 2016

Responsive

Good

Updated 15 August 2016

Well-led

Good

Updated 15 August 2016

Checks on specific services

People with long term conditions

Good

Updated 6 May 2016

The practice is rated as good for the care of people with long-term conditions.

  • The practice held information about the prevalence of specific long term conditions within its patient population such as diabetes, chronic obstructive pulmonary disease (COPD), cardio vascular disease and hypertension. This information was reflected in the services provided, for example, regular reviews of conditions with the practice nurse, treatment and screening programmes. The practice contacted these patients to attend regular reviews to check that their health and medication needs were being met.

  • Performance for diabetes related indicators was higher than the national average. For example, the percentage of patients with diabetes, on the register, who had had an influenza immunisation in the preceding 1 August 2014 to 31 March 2015 was 96% compared to the national average of 94%.

Families, children and young people

Good

Updated 6 May 2016

The practice is rated as 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, for example, children and young people who had a high number of A&E attendances. Immunisation rates were comparable or better than Clinical Commissioning Group (CCG) averages for all standard childhood immunisations. For example, measles, mumps and rubella dose two for children upto the age of five was 95% compared to CCG average of 90%.

  • In the last 12 months, 73% of patients diagnosed with asthma, had undergone a review of their care compared to the national average of 75%.

  • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

  • In the last 5 years 83% of patients had received cervical screening compared to the national average of 82%.

Appointments were available outside of school hours and the premises were suitable for children and babies

Older people

Good

Updated 6 May 2016

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

  • The practice offered proactive, personalised care plans with regular reviews, with alerts sent to a web-based application, designed to enhance information sharing and collaborative working for the North West Ambulance Service, including notifications of ‘Do Not Attempt Resuscitation’ directives. This ensured that emergency services had current information about patients, if required.

  • Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people. The practice kept up to date registers of patients’ health conditions. The practice had identified patients who were at risk of unplanned hospital admissions and supported these patients to stay well at home, avoiding unplanned hospital admission.

Working age people (including those recently retired and students)

Good

Updated 6 May 2016

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

  • The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs for this age group.

People experiencing poor mental health (including people with dementia)

Good

Updated 6 May 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

  • The practice maintained a register of patients with mental health problems in order to regularly review their needs and carry out annual health checks and updates to their care plans. The practice staff liaised with other healthcare professionals to help engage these patients to ensure they attended reviews.

  • The practice carried out advance care planning for patients with dementia.

  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

  • Staff had an understanding of how to support patients with mental health needs and dementia.

People whose circumstances may make them vulnerable

Good

Updated 6 May 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including homeless people and those with a learning disability.

  • The practice offered longer appointments for patients with a learning disability.

  • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people.

  • The practice informed vulnerable patients about how to access various support groups and voluntary organisations.

  • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.