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New Collegiate Medical Centre Good


Inspection carried out on 23/06/2020

During an inspection looking at part of the service

We carried out a desktop focused inspection at New Collegiate Medical Centre on 23 June 2020. We had previously inspected the practice in March 2019 where the practice overall rating was good, with the key question of safe rated as requires improvement. We issued the practice with a requirement notice for a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance) following the previous inspection. The full comprehensive report following the inspection in March 2019 can be found on our website here:

This inspection focused on the following key questions: safe.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we reviewed action plan from the provider
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for the domain of safe.

We found that:

  • A system for managing significant events and safety alerts had been introduced.
  • A new process for the checking of blank prescriptions had been developed.
  • A new policy and procedure had been developed to monitor new locum recruitment checks.
  • Clinical audits had more structure and clear dates documented.

Inspection carried out on 12 March 2019

During a routine inspection

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.

Inspection carried out on 30/06/2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at New Collegiate Medical Centre on 30 June 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing, safe, effective, caring, responsive and well led services to patients.

Our key findings were as follows:

  • Practice staff understood the importance of identifying and reporting when things had gone wrong.
  • Opportunities for learning from these events to prevent them reoccurring was maximised.
  • Clinical audits were regularly used to ensure the most effective and appropriate care was offered.
  • Patient’s needs were assessed and care was provided in line with best practice guidance.
  • Staff had received training appropriate to their role
  • Patients told us that they were treated with compassion, dignity and respect. They were happy with the care they had received
  • The practice recognised the needs of the population it serves and delivered it’s services accordingly.
  • The practice provided a safe environment for the care of it’s patients, facilities were clean and well maintained. Equipment was looked after appropriately.

We saw several areas of outstanding practice including:

  • Audits undertaken demonstrated the practice was performing well in the early diagnosis of dementia
  • The practice offered a weekly sexual health screening clinic, along with a full contraceptive service. This service was also available for patients who were not registered with the practice.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Ensure that relevant staff receive training in regards to the Mental Capacity Act 2005

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice