The Care Quality Commission
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Archived: Carrfield Medical Centre

Overall: Good read more about inspection ratings

Carrfield Street, Sheffield, South Yorkshire, S8 9SG (0114) 258 4724

Provided and run by:
Carrfield Medical Centre

All Inspections

27 October 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 16 December 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to the regulatory breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014; Regulation 12 Safe Care and Treatment; Regulation 16 Receiving and Acting on Complaints; Regulation 17 Good Governance and Regulation 19 Fit and Proper Persons employed.

We carried out a focused inspection on 27 November 2016 to check that the practice had followed their action plan and to confirm that they now met the 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 Carrfield Medical Practice on our website at www.cqc.org.uk.

Overall the practice is rated as good. Specifically,following the focused inspection we found the practice to be good for providing safe, effective, responsive and well-led services.

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

  • Systems and processes were in place to keep people safe. For example, a Legionella risk assessment had been carried out in June 2016, and a new refridgerator for the storage of vaccinations had been purchased and was not over stocked with products.
  • Disclosure and barring service (DBS) checks had been completed for all staff.
  • An action arising from the annual infection prevention and control audit had been carried out i.e. new chairs were seen in the waiting room.
  • There was a system in place for reporting and recording significant events. We saw evidence that these significant events had been reviewed, discussed at practice meetings and learning had taken place as a result.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. We saw evidence that a system was in place to ensure that clinicians were kept up to date with national guidance and MHRA alerts.
  • We saw evidence that the management of prescriptions complied with NHS Protect Guidance.
  • The practice had established a programme of internal audit to monitor quality and to make improvements.
  • We saw that improvements were made to the quality of care as a result of complaints and we saw a complaints process and register of actions.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

16 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Carrfield Medical Practice on 16 December 2015. Overall the practice is rated as requires improvement.

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

  • Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not thorough enough. We did not see evidence that people received a verbal or written apology if appropriate.
  • Risks to patients were assessed and managed, with the exception of those relating to recruitment checks and a legionella risk assessment of the building.
  • Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
  • Urgent appointments were available on the day they were requested.
  • The practice had a number of policies and procedures to govern activity, but some were overdue a review.
  • Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

The areas where the provider must make improvements are:

  • Ensure they have a complaints procedure in place which is fully responsive and in line with recognised guidance.
  • Investigate safety incidents thoroughly and ensure that people affected receive reasonable support and a verbal and written apology.
  • Introduce robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.
  • Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines.
  • Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
  • Ensure management of prescriptions complies with NHS Protect guidance.
  • Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner.
  • Take action to address identified concerns with infection prevention and control practice.
  • Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements.
  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Ensure that all fridges which are used to store medications are checked so that the correct temperature regulation is maintained, and to avoid over-storage of products.

In addition the provider should:

  • Consider a continuous quality improvement programme to include clinical audit, medication optimisation and other performance activity to improve outcomes for patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice