19th September 2017
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at The Waterside Health and Wellbeing Centre on September 19th 2017. Overall the practice is rated as Good.
Our key findings across all the areas we inspected were as follows:
- The practice had been managed via a caretaker agreement by Cornerstone Healthcare CIC since October 2016 and this provider was making significant improvement to patient outcomes.
- There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
- The practice had clearly defined and embedded systems to minimise risks to patient safety; however photographic identity checks were not always in place and employment references for locums were not recorded. The locum staff had been employed prior the current provider taking over the contract for the service.
- Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
- Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
- Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
- Patients we spoke with said they found it easy to make an appointment with the GP and there was continuity of care, with urgent appointments available the same day.
- 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 proactively sought feedback from staff and patients, which it acted on.
- The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
We saw an area of outstanding practice:
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The practice provided holistic care, treatment and advocacy to vulnerable patients including those with health and spiritual needs for example those living in poverty and experiencing social exclusion. This included funded support from a practice chaplain, a worker supporting asylum seekers and a worker supporting people living in poverty.
The areas where the provider must make improvement are:
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Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas where the provider should make improvements are:-
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The practice should continue to develop the patient participation group in order to reflect the needs of the community.
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Clinical audits should be further developed and completed to demonstrate quality improvement.
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The protocol to monitor the quality of care delivered and referrals made by GP locums should be fully embedded.
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All staff appraisal documentation should be completed.
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Consider a hearing loop in the reception area.
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The practice should continue to identify and support patients who are also carers.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice