The Care Quality Commission
  • Doctor
  • GP practice

Archived: The Tickhill & Colliery Medical Practice Also known as The Colliery Surgery

Overall: Good read more about inspection ratings

Scrooby Road, Harworth, Doncaster, South Yorkshire, DN11 8JT (01302) 741860

Provided and run by:
The Tickhill and Colliery Medical Practice

All Inspections

17 May 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 13 October 2015. Breaches of legal requirements was were found.  After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to the regulatory breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulation 19 Fit and proper persons employed. 

We undertook this focused inspection on 17 May 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Tickhill & Colliery Medical Practice on our website at www.cqc.org.uk. 

Overall the practice is rated as Good.

Specifically, following the focused inspection we found the practice to be good for providing safe and well-led services. Our key findings across all the areas we inspected were as follows: 

  • Staff who acted as chaperones had received training for the role in January 2016. Disclosure and barring service (DBS) checks were also completed for all staff and an annual infection prevention and control audit had been completed on 31 December 2015. We saw evidence that action was taken to address any improvements identified as a result.
  • We reviewed two personnel files for staff starting at the practice in June 2016. We found appropriate recruitment checks had been undertaken.
  • The partners had reviewed the governance framework to support performance and deliver good quality patient care. We saw evidence that all of the clinical and non-clinical policies and procedures had been reviewed and were available to all staff via their desktop on the practice computer.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

13 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Tickhill & Colliery Practice on 13 October 2015. 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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
  • The Quality and Outcomes Framework data showed patient outcomes were average or just below for the locality. Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
  • 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.
  • Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments.
  • The practice had a number of policies and procedures to govern activity, but some were over three years old and were past the review dates of 2013 and 2014. The practice did not hold regular governance meetings and issues were discussed at ad hoc meetings.

The areas where the provider must make improvements are:

  • The practice must take immediate action to ensure its recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 to ensure necessary employment checks are in place for all staff. Specifically, this includes completing Disclosure and Barring Service (DBS) checks for those staff that need them.

In addition the provider should:

  • Review arrangements for documenting actions taken as a result of best practice guidance and patient safety alerts.
  • All staff must have access to appropriate up to date policies, procedures and guidance in order to carry out their role.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice