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Archived: Roman Way Medical Centre Good

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Reports


Inspection carried out on 26 September 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Roman Way Medical Centre on 12 January 2017. The overall rating for the practice was requires improvement. The full comprehensive report on the 12 January 2017 inspection can be found by selecting the ‘all reports’ link for Roman Way Medical Centre on our website at www.cqc.org.uk.

This inspection was a desk based review carried out on 26 September 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 at our previous inspection on 12 January 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

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Overall the practice is now rated as good.

Our key findings were as follows:

  • Processes were in place to ensure QOF performance was monitored with a view to improvement..

  • Systems were in place to improve the uptake for the national cervical screening programme.

  • The practice had undertaken a patient survey into the provision of nursing care and found an improvement in the way the nurse listened, treated patients and involved them in their care.

  • Processes were in place to raise the awareness of carers.

  • A cleaning schedule for the cleaning of hand held clinical equipment had been produced and was up to date.

  • All medical emergency equipment was housed in one place and all staff were aware of the location.

The areas where the provider should make improvement are:

  • Continue to monitor and improve the cervical screening uptake rate.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 12 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Roman Way Medical Centre on 12 January 2017. Overall the practice is rated as requires improvement.

The practice was previously inspected in March 2016. It was given an overall rating of requires improvement. The practice was found good for providing an effective and responsive service and requires improvement for providing a caring and well led service. The practice was found inadequate for providing a safe service and was found in breach of regulations 12 (safe care and treatment), 17 (good governance), 18 (staffing) and 19 (fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. When we re-inspected we found that the matters leading to these breaches had been addressed.

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

  • The practice was aware of the performance challenges outlined in the poor QOF (Quality and Outcomes Framework) scores and had put a plan in place to address this and improve outcomes for patients.
  • The practice scored below average for many of the scores in the national patient survey, especially those relating to nursing services. The practice was aware of this and were putting plans in place to address this including putting performance plans for members of staff.
  • Risks to patients were assessed and managed. However emergency equipment was housed in a number of locations within the nurse’s room and not easy to get in an emergency. There was no log of cleaning of hand held clinical equipment such as spirometer, nebuliser or ear irrigator.
  • There was an open and transparent approach to safety and a system was in place for reporting and recording significant events.
  • 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.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. However once at the practice, patients said that there was a long wait to see the GP. The practice was aware of this matter and were addressing it with individual GPs.
  • 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 sought feedback from staff and patients, which it acted on. The practice had developed a virtual patient participation group (PPG) following the difficulties found in forming a physical PPG.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

  • Investigate further ways to improve QOF scores.

  • Identify ways to improve the scores from the national patient survey in relation to patient satisfaction with the service.

The areas where the provider should make improvement are:

  • Produce a schedule for the cleaning of hand held clinical equipment.

  • Ensure emergency equipment is easily accessible and that all staff know of the location.

  • Look into ways to improve the uptake for the cervical screening programme.

  • To review how patients with caring responsibilities are identified and recorded on the patient record system to ensure information, advice and support is made available to all.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 24 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Roman Way Medical Practice on 24 March 2016. 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. However there was no effective recording system and patients did not always receive a written apology.
  • Risks to patients were not assessed and well managed, including infection control processes, fire procedures and medicines management.
  • The practice did not have an effective system to ensure that emergency equipment and medicines were fit for use.
  • Staff employment files did not include the mandatory pre-employment checks.
  • There was a lack of training in basic life support for non-clinical members of staff.
  • Data showed patient outcomes were mixed compared to the locality and nationally.
  • Audits had been carried out and we saw evidence that audits were driving improvement in performance to improve patient outcomes.
  • Patients said they were treated with compassion, dignity and respect.
  • The practice scored lower than the clinical Commissioning Group (CCG) and national average in the GP Patient survey. The practice had not produced an action plan to address the issues the survey identified.
  • Urgent appointments were usually available on the day they were requested.
  • The practice had a number of policies and procedures to govern activity, but these were not routinely accessible to staff.
  • The practice did not have an active patient participation group (PPG).

The areas where the provider must make improvements are:

  • Ensure that patient details are kept confidential at all times and not displayed within the reception area.

  • Carry out an infection control audit, health and safety risk assessment and fire risk assessments to ensure risks are identified and acted upon.

  • Ensure pre-employment checks are obtained and kept on file and that staff are provided with mandatory training including basic life support.

  • Carry out electrical equipment testing.

  • Ensure blank prescription pads are kept securely.

  • Replace emergency oxygen and masks and ensure that there is a system for checking that they are in working order.

  • Produce a formal system for reporting significant events and complaints to enable identification and learning.

  • Ensure practice policies are accessible to all staff.

In addition the provider should:

  • Consider formalising the contract for the provision of cleaning and produce schedules for the cleaning of the premises.
  • Ensure PGD’s are accessible for the practice nurse to review as necessary.
  • Introduce a system to check whether emergency medicines are in date.
  • Ensure that all carers are appropriately identified.
  • Review patient feedback from the GP Patient Survey and PPG to ensure patient satisfaction.
  • Revise the practice’s business continuity plan.

Where a practice is rated as inadequate for one of the five key questions or one of the six population groups the practice will be re-inspected within six months after the report is published. If, after re-inspection, the practice has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place the practice into special measures. Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice