The Care Quality Commission
  • Doctor
  • GP practice

The Colne Practice

Overall: Good read more about inspection ratings

Colne House Surgery, 99a Uxbridge Road, Rickmansworth, Hertfordshire, WD3 7DJ (01923) 776295

Provided and run by:
The Colne Practice

All Inspections

29 January 2020

During an inspection looking at part of the service

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

18 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Colne Medical Practice on 18 March 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for older people, people with long term conditions, working age people, families, children and young people, those people whose circumstances make them vulnerable, and those people experiencing poor mental health (including 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 managed, with the exception of those relating to infection control and recruitment checks.
  • 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.
  • Patients said they found it easy to make an appointment with a named GP and that 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.

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

Importantly the provider should:

  • Ensure the recruitment policy includes all necessary pre-employment checks for all staff to include photographic identify, disclosure and barring service check and a reference check.
  • Update policies specifically infection control, to ensure they accurately reflect the actions to be taken.
  • The practice should ensure that infection control training is completed and an infection control audit completed following this.
  • Ensure appraisal takes place for the nursing staff.
  • Repair or remove the damaged seating and remove plugs from clinical areas.
  • Consider regular meetings with administration and reception staff.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

16 August 2013

During a routine inspection

We found the service to be welcoming with friendly staff. Practice information was displayed for people who used the service, including health promotion, access to support services and other services available. There was a touch screen booking in facility in the reception area and appointments could be made on line using the practice website, by telephone or in person at the surgery.

We spoke with eight people who all spoke highly of the services provided to them. We also spoke with staff who said they enjoyed working in the practice.

People's needs were assessed and care and treatment was planned and delivered in line with their individual wishes. One person said, "It's nice always seeing the same doctor. My doctor knows all my family." Another person said, "Everyone is very polite. I can always get an appointment.'

We saw that there was a system to ensure repeat prescriptions were available promptly and medicines that were kept at the practice were stored safely.

The practice had an electronic records system, which was used by all staff. Paper records received from other areas, when people changed practices, were stored safely. However, there was a significant backlog of paper records which had not yet been summarised into an electronic format.