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Dr Wignell and Partners Good Also known as Windrush Surgery

Inspection Summary


Overall summary & rating

Good

Updated 7 June 2017

Letter from the Chief Inspector of General Practice

Our previous comprehensive inspection at Dr Wignell and Partners (Windrush Surgery) on 03 October 2016 found breaches of regulations relating to the safe, effective and well-led delivery of services. The overall rating for the practice was requires improvement. Specifically, we found the practice to require improvement for provision of safe, effective and well led services. It was good for providing caring and responsive services. Consequently we rated all population groups as requires improvement. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Dr Wignell and Partners on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 3 October 2016. This report covers our findings in relation to those requirements and improvements made since our last inspection.

We found the practice had made improvements since our last inspection. At our inspection on the 10 May 2017 we found the practice was meeting the regulations that had previously been breached. We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well led services. Overall the practice is now rated as good. Consequently we have rated all population groups as good.

Our key findings were as follows:

  • The practice had taken steps to improve governance framework and leadership structure.
  • The practice had taken steps to improve the risks associated with the premises.
  • There was an effective system in place for reporting and recording significant events and complaints. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Learning outcomes were identified and lessons learned were communicated effectively.
  • Data showed the practice had demonstrated improvements in patient’s outcomes.
  • All staff who acted as a chaperone had received a Disclosure and Barring Service (DBS) checks to keep patients safe and safeguarded from abuse.
  • Staff we spoke with on the day of inspection was aware about a whistleblowing policy.
  • Staff we spoke with informed us the management was approachable and always took time to listen to all members of staff.
  • We found staff annual appraisals had not always completed in a timely manner. However, dates were planned to complete all appraisals by the end of June 2017.

In addition the provider should:

  • Review and monitor the system in place to ensure all staff have received annual appraisals in a timely manner.
  • Arrange repairs to fix the flooring in both treatment rooms.
  • Improve the outcomes for patients with dementia.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 7 June 2017

The practice is rated as good for providing safe services as there are areas where it must make improvements.

  • When we inspected the practice in October 2016 we found concerns relevant to management of legionella, monitoring of fire safety and gas safety, hepatitis B immunisation records, and Disclosure and Barring Scheme (DBS) checks were not carried out for non-clinical staff undertaking chaperoning duties. Lessons were not always identified and shared as a result of significant events and complaints. We saw that flooring in one treatment room was not impervious (it was not sealed where it met the walls) meaning dirt could accumulate.
  • At the inspection on 10 May 2017, we found the practice had made some improvements since our last inspection in October 2016, but some work was still in the progress and dates were planned for the completion. For example:
  • A fire risk assessment had been carried out and new fire safety doors installed in the premises. However, the practice was in the process of installing an electronic fire detection and alarm system, which was not activated on the day of inspection.
  • The practice had not taken any steps to fix the flooring in one treatment room which was not impervious (it was not sealed where it met the walls) meaning dirt could accumulate. This issue was identified in the previous inspection report. We observed that the flooring in second treatment room required similar repair. This posed a risk of spread of infections in treatment rooms used for taking blood and injections.
  • Disclosure and Barring Scheme (DBS) checks were undertaken for all staff undertaking chaperoning duties. All staff who acted as chaperones were trained for the role.
  • The practice had reviewed the process for investigating and implementing change following incidents, significant events and complaints to ensure actions are completed.
  • Records of hepatitis B immunisation were available for all clinical staff.

Effective

Good

Updated 7 June 2017

The practice is rated as good for providing effective services as there are areas where it must make improvements.

  • When we inspected the practice in October 2016, we found concerns relevant to medicine reviews, exception reporting and staff training. Health checks and care plans were not always completed for patients on the learning disabilities register. Some appraisals were overdue.
  • At the inspection on 10 May 2017, we found the practice had made some improvements since our last inspection in October 2016, but some work was still in the progress and dates were planned for the completion. For example:
  • We noted that annual staff appraisals were not always completed on time. However, dates were planned to complete all appraisals by end of June 2017.
  • We checked staff training records and noted that some role specific training was not organised in a timely manner including basic life support and immunisation training. However, we saw evidence that a basic life support training session was booked on 17 May 2017 (a week after the inspection).
  • The practice had reviewed and improved the systems in place to effectively monitor medicine reviews for patients with long term conditions, and care plans and health checks were completed for patients with learning disabilities.
  • However, the practice was required to improve the outcomes for patients with dementia. For example, 68% (23 out of 34 patients) structured annual reviews had been undertaken for patients with dementia.
  • We noted the practice had demonstrated improvements in reducing exception reporting for Quality and Outcomes Framework (QOF) year 2016-17. However, recent national data was not available to validate this information.

Caring

Good

Updated 7 June 2017

Responsive

Good

Updated 7 June 2017

Well-led

Good

Updated 7 June 2017

The practice is rated as good for providing well-led services as there are areas where it must make improvements.

  • When we inspected the practice in October 2016, we observed that the practice had limited governance framework and governance monitoring of specific areas required improvement, such as, staff training, appraisals, monitoring of patient care and the management of the premises were not adequate and Disclosure and Barring Scheme (DBS) checks to ensure risks were managed appropriately. Learning outcomes were not always identified from incidents and complaints.
  • At the inspection on 10 May 2017, we found the practice had made improvements since our last inspection in October 2016, but some work was still in the progress and dates were planned for the completion.
  • The practice had taken steps to improve governance framework and leadership structure.
  • Learning outcomes were identified from incidents and complaints, and lessons learned were always communicated widely enough to ensure risks were managed appropriately.
  • The practice had demonstrated improvements in monitoring of patient outcomes.
  • Staff we spoke with on the day of inspection were aware of the whistleblowing policy. Staff informed us they felt supported in their role, and that the management team was approachable and always took time to listen to all members of staff.
Checks on specific services

People with long term conditions

Good

Updated 7 June 2017

The provider had resolved the concerns for safe, effective and well-led identified at our inspection on 3 October 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Families, children and young people

Good

Updated 7 June 2017

The provider had resolved the concerns for safe, effective and well-led identified at our inspection on 3 October 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Older people

Good

Updated 7 June 2017

The provider had resolved all the concerns for safe, effective and well-led identified at our inspection on 3 October 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Working age people (including those recently retired and students)

Good

Updated 7 June 2017

The provider had resolved the concerns for safe, effective and well-led identified at our inspection on 3 October 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People experiencing poor mental health (including people with dementia)

Good

Updated 7 June 2017

The provider had resolved the concerns for safe, effective and well-led identified at our inspection on 3 October 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People whose circumstances may make them vulnerable

Good

Updated 7 June 2017

The provider had resolved the concerns for safe, effective and well-led identified at our inspection on 3 October 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

  • It offered annual health checks and care plans for patients with learning disabilities. Care plans were completed for 22 patients out of 27 patients on the learning disability register.