• Doctor
  • GP practice

Northumberland Park Medical Group, Shiremoor Resource Centre

Overall: Good read more about inspection ratings

Earsdon Road, Shiremoor, Newcastle upon Tyne, Tyne and Wear, NE27 0HJ (0191) 253 7892

Provided and run by:
Northumberland Park Medical Group, Shiremoor Resource Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Northumberland Park Medical Group, Shiremoor Resource Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Northumberland Park Medical Group, Shiremoor Resource Centre, you can give feedback on this service.

8 December 2023

During an inspection looking at part of the service

We carried out a targeted assessment of Northumberland Park Medical Group in relation to the responsive key question. This assessment was carried out on 8 December 2023 without a site visit. Overall, the practice is rated as Good. We rated the key question of responsive as Good.

Safe - Good

Effective – Good

Caring - Good

Responsive – Good

Well-led – Good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for the

Northumberland Park Medical Group on our website at www.cqc.org.uk

Why we carried out this review

We carried out this assessment as part of our work to understand how practices are working to try to meet demand for access and to better understand the experiences of people who use services and providers.

We recognise the work that GP practices have been engaged in to continue to provide safe, quality care to the people they serve. We know colleagues are doing this while demand for general practice remains exceptionally high, with more appointments being provided than ever. In this challenging context, access to general practice remains a concern for people. Our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. These assessments of the responsive key question include looking at what practices are doing innovatively to improve patient access to primary care and sharing this information to drive improvement.

How we carried out the assessment

This assessment was carried remotely.

This included:

  • Conducting staff interviews using video conferencing.
  • Requesting evidence from the provider.

Our findings

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

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

We found that:

We rated responsive as good because:

  • The practice had a proactive approach to identifying the needs of patients and responding to them.
  • The practice understood the needs of its local population.
  • National GP Patient Survey data was high over several years in relation to how easy it was to get through to the practice via the telephone. This was including during COVID-19. The other indicators were above local and national averages.
  • Feedback we received from patients regarding appointments and access was mostly positive.
  • The practice dealt with complaints in a timely manner and learned from them.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

28 April 2021

During a routine inspection

We carried out an announced comprehensive inspection at Northumberland Park Medical Group, Shiremoor Resource Centre on 28 April 2021 to follow up on breaches of regulations identified at a previous inspection on 6 March 2020. Following our previous inspection on 6 March 2020, the practice was rated Requires Improvement overall and for the key questions of Safe, Responsive and Well led and Good for the key questions of Effective and Caring.

At this inspection we found that the practice had made many improvements and is now rated as Good overall.

The key questions are rated as follows,

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Northumberland Park Medical Group, Shiremoor Resource Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on:

  • Breaches of regulations or ‘shoulds’ identified in the previous inspection
  • Ratings carried forward from previous inspection

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • Remote staff questionnaires.
  • A short site visit.

Our findings

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

  • what we found when we inspected
  • 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 all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • Improve their approach to monitoring by instituting a regular audit cycle for compliance with Medicines and Healthcare products Regulatory Agency alerts
  • Review and improve child protection records with regard to clearer flagging of child protection on records, more detail on the home page and reviews to check that obsolete flags are removed
  • Take steps to improve the monitoring of patients’ in relation to the use of medicines, including high risk medicines, where this is required.
  • Review and improve the documentation and recording of what is included in a medication review

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

06 Mar 2020

During a routine inspection

We carried out an announced comprehensive inspection at Northumberland Park Medical Group, Shiremoor Resource Centre on 6 March 2020 to follow up on breaches of regulations identified at a previous inspection on 22 and 29 January 2019.

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

  • what we found when we inspected
  • 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 requires improvement overall.

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

  • There were gaps in systems to assess, monitor and manage risks to patient safety.
  • Receptionists had not been given guidance on identifying deteriorating or acutely unwell patients but due to the way in which the appointment system worked they were being asked to signpost some patients who telephoned for a same-day appointment to other services.
  • The practice was not sharing learning from significant events externally using SIRMS and there appeared to be a delay in the review of some significant events.
  • There was prescription stationary on the premises which had not been logged.

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

  • The appointment system required patients to call the practice between 8.30am and 9.30am if they wanted a same-day GP appointment. Patients calling after this time were told to call back the next day or were diverted to other services, however there was no system in place to determine if it was safe to do so.
  • Patient feedback regarding the appointment system was below average and lower than at the previous inspection.

We rated the practice as requires improvement for providing well-led services because:

  • While the practice had made some improvements since our inspection on 22 and 29 January 2020, it had not appropriately addressed the Requirement Notice in relation to good governance. At this inspection we also identified additional concerns that put patients at risk.
  • Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
  • The practice did not have clear and effective processes for managing risks, issues and performance.

These areas affected all population groups so we rated all population groups as requires improvement.

We rated the practice as good for providing effective and caring services because:

  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We are mindful of the impact of the Covid-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service to keep people safe and to hold providers to account where it is necessary for us to do so.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • 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:

  • Continue to follow the appraisal timetable put in place to ensure all staff receive an appraisal every 12 months.
  • Formalise the supervision process for salaried and locum GPs.
  • Formalise the process for sharing clinical guidance between clinicians at the practice.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

22/01/2019 and 29/01/2019

During a routine inspection

We carried out an announced comprehensive inspection at Northumberland Park Medical Group, on 22 and 29 January 2019, as part of our inspection programme.

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

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

The practice was rated as requires improvement for providing safe services because:

  • The arrangements for documenting the outcomes of the practice’s multi-disciplinary team safeguarding meetings and significant events were not effective. Although staff told us lessons were learnt when things went wrong, it was not always clear whether agreed changes had been reviewed and implemented, to make sure they had helped to drive improvements.
  • Immunisation histories had not been obtained for some non-clinical staff.
  • The practice’s health and safety risk assessment did not comprehensively address risks to patients’ safety.
  • The practice’s locum GP pack was out-of-date and there was no lead GP to oversee the performance of locum and salaried GPs.

The practice was rated as requires improvement for providing effective services because:

  • The practice did not have a comprehensive programme of quality improvement activity.
  • The practice did not have an effective staff appraisal system.
  • The practice’s arrangements for documenting staff inductions were not effective.
  • The Quality and Outcome Framework long-term conditions clinical indicators relating to the treatment of patients with asthma and atrial fibrillation, were lower than the local clinical commissioning group and national averages.
  • Follow-up consultations did not always take place following a patient’s discharge from hospital.

Because these concerns impacted on all population groups, we have rated them as requires improvement for providing effective services.

The practice was rated as good for providing caring services because:

  • Feedback from people who used the service was positive about the way that staff treated them.
  • Staff treated patients with kindness and respect and involved them in decisions about their care and treatment. Most of the practice’s results from the national GP patient survey, regarding how patients were treated, were higher than the local clinical commissioning group and national averages.

The practice was rated as good for proving responsive services because:

  • Services were tailored to meet the needs of individual patients. They were delivered in a flexible way, that ensured choice and continuity of care.
  • Most patients told us they could access care and treatment in a timely way.

The practice was rated as requires improvement for well-led because:

  • The practice did not have a clear vision and credible strategy to provide high quality sustainable care.
  • Leaders had not identified the actions needed to address the challenges they faced, regarding the delivery of high-quality care and the sustainability of the service. A development programme for leaders was not in place.
  • The practice’s governance arrangements were not always effective. There were shortfalls in the practice’s systems and processes, and in the leadership oversight of these, which could place some patients at risk of not receiving appropriate care and treatment.

We also found that:

  • Effective arrangements were in place to maintain a safe patient environment. Regular checks were carried out to make sure clinical, and other equipment, was safe to use.
  • The practice had effective systems for the appropriate and safe use of medicines.
  • Arrangements had been made to ensure care and treatment was delivered in line with current legislation, standards and evidence-based guidance.
  • Most outcomes for people who use the service were positive, consistent and met expectations.

The overall rating for this practice was requires improvement due to concerns in providing safe, effective and well-led services. We are rating the practice as good overall for providing responsive services, including all the population groups, because patients could access timely care and treatment which had been tailored to meet their needs.

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.
  • Ensure persons employed in the provision of the regulated activity receive appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

The areas where the provider should make improvements are:

  • Improve how patients who are also carers are identified, to enable this group of patients to access appropriate care and support.
  • Provide patients with access to information about complaints in the reception waiting areas.
  • Review the arrangements for monitoring emergency hospital admissions, sharing information with community services and social services, and identifying patients at risk of suicide or self-harm.
  • Review the effectiveness of the practice’s performance management system.
  • Review the arrangements on the practice’s website for providing patients with information about support groups.
  • Consider providing the practice’s infection lead with advanced training in the prevention and management of infection control.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

24 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Northumberland Park Medical Group, Shiremoor Resource Centre on 24 March 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, well-led, effective, caring and responsive services. It was outstanding for providing services for the population group of people with long-term conditions. It was also good for providing services for the following population groups: Older people; Families, children and young people; Working age people (including those recently retired and students); People whose circumstances may make them vulnerable; People experiencing poor mental health (including people with dementia).

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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • The majority of patients said they were able to get an appointment with a GP when they needed one, with urgent appointments available the same day.
  • The practice offered pre-bookable early morning appointments on Tuesdays, Wednesdays and Fridays which improved access for patients who worked full time through the week.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure in place for clinical areas and staff felt supported by management. The practice proactively sought feedback from staff and patients, which they acted on.
  • The administrative and support staff worked well together as a team.

We saw the following areas of outstanding practice:

  • The practice had achieved significantly higher cervical screening rates (93.8%) compared to the national average (81.9%). The practice nurse led on this and opportunistically reviewed their patients’ last screening date, when this was appropriate to do so, during their patients’ appointments. If they noticed they were approaching their due date, they would offer to make an appointment for the patient while they were there. This showed the practice were not simply reliant on the central recall process for cervical screening, but were taking responsibility for managing this process locally too.
  • In total, we were told that 866 patients registered with the practice had some form of care plan agreed and in place. This represented 16% of the practice population and included all patients with chronic diseases, those identified to be at high risk of hospital admission and patients identified as being in vulnerable circumstances.

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

Importantly the provider should:

  • Improve the systems used to centrally record, monitor and review significant events within the practice.
  • Continue to review the appointments process as feedback from a number of sources indicated it was difficult to get a same day appointment with a GP when patients felt their need was urgent.
  • Endeavour to improve team working within the practice between clinical and non-clinical staff on management and business matters.
  • Review its arrangements for nursing provision; especially to provide cover for holidays.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

25 February 2014

During an inspection looking at part of the service

We found that appropriate measures were in place to monitor and maintain cleanliness and infection control within the practice. The practice had a designated individual with responsibility for infection control. Regular weekly audits were undertaken to ensure that the practice was clean and that there was adequate equipment available for staff to work safely and effectively. All staff had received Hepatitis B immunisations to protect them in the event of injury.

12 November 2013

During a routine inspection

People expressed their views and were involved in making decisions about their care and treatment. We saw that staff dealt with enquiries from patients as discretely as possible. One patient told us, 'The doctor sat for ages explaining things.'

Patients we spoke with were complimentary about the care they received. We saw there were systems in place to monitor and review people's care and treatment. One patient told us, 'This practice is great. There is a massive difference here from my last practice. The whole quality of the visit is better'

The practice had in place safeguarding policies for both children and vulnerable adults. There was an identified lead clinician and regular discussion between staff about any safeguarding or concerning situations.

The practice was well organised and presented as clean, tidy and generally well maintained. However, processes to reduce the risk of infection were not always in place or adhered to.

The provider had a recruitment policy in place. General practitioners and nurses employed within the practice were checked to ensure they had an up to date registration with the appropriate professional body.