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The Borchardt Medical Centre Good


Review carried out on 28 December 2019

During an annual regulatory review

We reviewed the information available to us about The Borchardt Medical Centre on 28 December 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 13 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Borchardt Medical Centre, 62 Whitchurch Road, Withington, Manchester, M20 1EB on 16 December 2015. During the inspection we identified breaches of regulation 12 (Safe Care and Treatment), regulation 17 (Good governance) and regulation 19 (Fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches resulted in the practice being rated as requires improvement for being safe and well-led and good for being effective, caring and responsive. Consequently the practice was rated as requires improvement overall.

The specific concerns identified were:

  • The risk assessments associated with the environment were not available to view on the day of inspection. Systems to maintain emergency equipment had not been followed and emergency equipment was found to be out of date.

  • Systems and processes were not in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients. Staff training was not managed in such a way as to ensure appropriate training and professional development was carried out to enable them to carry out the duties they were employed to perform. Some policies and procedures were found to be out of date and did not reflect current practice.

  • The provider had not followed recruitment procedures to establish all information specified in Schedule 3 was available in respect of all staff employed to ensure staff are safely and effectively recruited and employed.

An announced comprehensive inspection was carried out at on 27 March 2017. This report reflects the action that the practice has taken to address the concerns identified during our initial inspection.

Overall the practice is now rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • The practice worked in collaboration with other health and social care professionals to support patients’ needs and provided a multidisciplinary approach to their care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice provided appropriate support for end of life care and patients and their carers received good emotional support.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Urgent appointments were usually available on the day they were requested. However, patients did report difficulties booking appointments by telephone.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice was a member of the South Manchester GP Federation (SMGPF) a group of 24 GP practices working in partnership to improve patient access to health care.
  • The practice worked closely with the nursing home team. This team of nurses carried out health reviews and provided advice on the management of acute and long term conditions for nursing home residents with the aim of reducing unnecessary admission to hospital. This was achieved by enabling nursing home residents to access a range of community services.
  • The diabetes specialist nurse supported newly diagnosed patients and offered insulin initiation as required, which made this easier to access for patients.
  • The practice was involved with the co-production of services via Royal College of General Practitioners (RCGP) Future Hospital Scheme.

We saw an area of outstanding practice:

The GPs recognised that many patients attending the practice had non-medical conditions. In October 2015 the practice began a trial period of the social prescribing initiative in partnership with Southway Housing Trust to improve support for patient wellbeing. Social prescribing is a non-medical intervention used to support people to improve their health and wellbeing with referrals to community support services.

The practice was able to provide details of how this service had positively impacted on the health and wellbeing of the patients they had referred. As a result of the success of this venture social prescribing had been rolled out to other practices in the neighbourhood.

The areas where the provider should make improvements:

  • Continue to make efforts to encourage the development of a patient participation group.
  • Continue to identify and register those patients who were also carer’s.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection carried out on 16/12/2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Borchardt Medical Centre 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 and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Patients received a written explanation and apology.
  • Systems to monitor the functionality of equipment to deal with medical emergencies had not been maintained, resulting in the practice’s oxygen cylinder expiring.
  • Risks to patients and staff were not assessed and well managed, for example the required pre-employment checks were not consistently completed as part of the recruitment process and not all staff acting as chaperones had received Disclosure and Barring Service checks.
  • Data showed patient outcomes were in line with the locality and nationally.
  • Although some audits had been carried out to drive improvement in patient outcomes, these were not consistently re-audited to monitor that expected improvement was taking place.
  • There were gaps in staff training, particularly around infection control. Staff appraisals were not carried out regularly in order to identify training needs.
  • The majority of patients said they were treated with compassion, dignity and respect.
  • Urgent appointments were usually available on the day they were requested. However, patients did report difficulties booking appointments by telephone. On the day of inspection patients wishing to book a routine pre-bookable appointment were being asked to contact the practice in January as there were none available to book.
  • The practice had a number of policies and procedures to govern activity, but some were overdue a review, contained out of date information or did not reflect current practice.
  • The practice had proactively sought feedback from patients and had an active patient participation group.

The areas where the provider must make improvements are:

  • Ensure procedures are followed to monitor the functionality of equipment to deal with medical emergencies

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

  • Ensure staff receive appropriate support, training and supervision to carry out their role, for example mandatory training such as infection prevention and control, and that this training is managed to ensure its effectiveness.

  • Ensure a systematic approach to assessment and management of risk and review and update procedures and guidance to ensure the information is relevant to current practice.

In addition the provider should:

  • Improve the availability of non-urgent appointments.

  • Ensure there is an auditable system for monitoring the recording of serial numbers on blank hand written and electronic prescriptions pads held in storage and once allocated to the GP so that their location is easily identified.

  • Ensure a planned programme of clinical and internal audits is established to enable the practice to monitor quality consistently and to make improvements as required quickly.
  • Record a business plan with priorities and strategies to provide focus and clarity on the vision of the service and allow the whole staff team to contribute to the development of the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice