New Collegiate Medical Centre

This practice is rated as Good overall. (Previous rating 06 2015– Good)

The key questions at this inspection are rated as:

Are services safe –Requires Improvement

Are services effective – Good

Are services caring – Good

Are services responsive – Good

Are services well-led – Good

We carried out an announced comprehensive inspection at New Collegiate Medical Centre on 12 March 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

• Structures, processes and systems to support good governance and management were in place. However, better communication was required to ensure that they were clearly set out, understood and effective for all staff.
• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a focus on continuous learning and improvement at all levels of the organisation.

We rated the practice as requires improvement for providing safe services because:

There was no formal process in place to monitor new locum recruitment checks. The system for managing significant events and safety alerts was not robust or clearly communicated. A fridge incident would have gone unnoticed, if checks had not been done by the by the inspection team on the day of inspection. Some of the single clinical audits had no dates documented. There was no process for checking of blank prescriptions.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Implement a practice mission statement and values.
• Implement a Patient Participation Group (PPG) in order to identify and act on patients’ views about the service.
• Complete infection control action plan in relation to blinds and slats.
• Implement a formal supervision structure of learning for the Advanced Nurse Prescriber.
• Review the communication between the clinicians and the practice manager in relation to the complaints process and health and safety risk assessments.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence tables for further information.