16 May 2019
During a routine inspection
This practice is rated as Good overall.
The key questions at this inspection are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We carried out an announced comprehensive inspection at Malzeard Road Medical Centre on 16 May 2019. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, as part of our inspection programme.
At this inspection we found:
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
- There were safeguarding processes and procedures in place and staff were trained to appropriate levels. The safeguarding contacts list did not contain a review date to indicate it contained the most up to date information. Following the inspection, the practice provided evidence that this had now been rectified.
- The practice demonstrated an improvement in quality indicators over the past 12 months.
- Clinical audits were undertaken and showed quality improvements within the practice.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Feedback from patients was positive regarding the staff in the practice and the care they received.
- The practice had taken action to improve the appointments offered in response to GP patient survey results.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
- Improvements had been made to the practice in the previous 12 months to provide stability and sustainability.
The areas where the provider should make improvements are:
- Record a review date on documents, such as the safeguarding contacts list, so staff are assured they are following the most up to date information.
- Continue to identify and support carers.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
Please refer to the detailed report and the evidence tables for further information.