Background to this inspection
Updated
19 March 2020
The Colne Practice provides a range of primary medical services from its premises at Colne House Surgery, 99a Uxbridge Road, Rickmansworth, Hertfordshire, WD3 7DJ.
The practice is part of the Watford Extended Access GP federation. The practice is also in the early stages of participating in a Primary Care Network (PCN). (A Primary Care Network is a group of practices working together to provide more coordinated and integrated healthcare to patients).
The provider is registered with CQC to deliver five Regulated Activities. These are: diagnostic and screening procedures; maternity and midwifery services; family planning services; surgical procedures; and treatment of disease, disorder or injury. Services are provided on a General Medical Services (GMS) contract (a nationally agreed contract) to approximately 10,400 patients. The practice has a registered manager in place. (A registered manager is an individual registered with CQC to manage the regulated activities provided).
The practice is within the Hertfordshire local authority and is one of 58 practices serving the NHS Herts Valleys Clinical Commissioning Group (CCG).
The practice team consists of six female and two male GP partners. There are two female salaried GPs. There is a clinical pharmacist, three practice nurses (one of whom is currently absent), two healthcare assistants, a practice manager, a finance manager, and 16 secretarial, administration and reception staff. In addition to the directly employed clinical pharmacist, a Primary Care Network employed clinical pharmacist also works from the practice.
The practice serves a slightly above average population of those aged 65 years and over. The practice population is predominantly white British and has a Black and minority ethnic (BME) population of approximately 13.3% (2011 census), most of whom are from south Asian communities. Information published by Public Health England rates the level of deprivation within the practice population as 10. This is measured on a scale of one to 10, where level one represents the highest levels of deprivation and level 10 the lowest.
An out of hours service for when the practice is closed is provided by Herts Urgent Care and can be accessed via the NHS 111 service.
Updated
19 March 2020
We carried out an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, this inspection looked at the following key questions: safe, effective and well-led.
Because of the assurance received from our review of information we carried forward the ratings for the following key questions: caring and responsive.
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 rated the practice as good overall. We rated the practice as requires improvement for the w
orking-age people (including those recently retired and students) population group and good for all other population groups.
We rated the practice as requires improvement for providing safe services because:
- The practice’s systems for the appropriate and safe use of medicines, including medicines optimisation, were not always comprehensive.
- Although not part of the requirement notice due to the practice’s immediate actions, or the level of concern, there were some issues that contributed to the requires improvement rating for the safe key question. They included those relating to: non-clinical staff DBS checks, staff vaccinations, and health, safety and premises risk related processes and documentation.
Please see the final section of this report for specific details of our concerns.
We rated the practice as good for providing effective and well-led services because:
- Patients received effective care and treatment that met their needs. The practice routinely reviewed the effectiveness and appropriateness of the care it provided. Staff had the skills, knowledge and experience to deliver effective care and treatment.
- The way the practice was led and managed promoted the delivery of high quality, person-centred care and an inclusive, supportive environment for staff. There was a focus on continuous learning and improvement at all levels of the organisation. Where we identified any concerns during our inspection, the practice took immediate action to respond or plans of action were developed to ensure any issues were resolved.
The area where the provider must make improvements is:
- Ensure care and treatment is provided in a safe way to patients.
Please see the final section of this report for specific details of the action we require the provider to take.
The areas where the provider should make improvements are:
- Strengthen policies, systems and processes at the practice. Especially those in relation to health and safety, premises and infection prevention and control risk related processes and documentation, water temperatures, an appropriate supply of emergency medicines, encouraging women to attend for their cervical screening, and increasing the provision and uptake of NHS checks for patients aged 40 to 74.
- Implement comprehensive staff related processes to include staff completing all essential training in a timely way at the appropriate level for their roles, a review of the Disclosure and Barring Service (DBS) check policy and process to determine who requires a check and ensure those not requiring a check have an appropriate risk assessment in place, a review of the chaperone policy to confirm the process in place and ensure it is fully adhered to, all staff receiving the required vaccinations, and that the eligible healthcare assistant completes the Care Certificate.
- Take steps so that the information available to patients through the practice’s website is comprehensive and up-to-date, including information about the complaints process.
- Provide additional methods for people to raise their views, suggestions and concerns including giving patients access to an active Patient Participation Group and an online comments facility.
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
Working age people (including those recently retired and students)
Updated
19 March 2020