- GP practice
Archived: Ewood Medical Centre
Important:
The provider of this service changed. See new profile
All Inspections
27 June 2017
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Ewood Medical Centre on 30 September 2016. The overall rating for the practice was good. However, the practice was rated as requires improvement for the key question of safe. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for Ewood Medical Centre on our website at www.cqc.org.uk.
This inspection was an desk-based review carried out on 27 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach to regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 that we identified in our previous inspection on 30 September 2016. This report covers our findings in relation to those requirements.
Overall the practice is now rated as Good.
Our key findings were as follows:
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Our previous inspection found that clinical waste was not being stored in line with practice policy. As part of this desk based inspection the provider demonstrated that clinical waste including waste in sharps bins was now securely stored in locked rooms to ensure it was not accessible to patients.
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Our September 2016 inspection found that the monitoring of vaccine fridge temperatures was not thorough. For this inspection the practice shared evidence with us that data loggers were now being used to ensure effective monitoring of vaccine fridge temperatures.
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In September 2016 we found systems to monitor stock of single use items and blank prescription paper were not comprehensive. We saw during this follow up inspection that more comprehensive systems had been implemented to monitor stock levels of single use items held on site as well as the location of blank prescription pads.
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In September 2016 documentation relating to risk management did not always indicate whether mitigating actions had been put in place. During this inspection we was updated documentation relating to risk management activity that clearly recorded timescales and completed dates for any mitigating actions necessary.
As a result of the improvements the practice has made, it is now rated as good for providing safe services.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
30 September 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Ewood Medical Centre on 30 September 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
- There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
- Risks to patients were generally assessed and managed. However, we identified gaps and opportunities for improvement related to risk management systems, processes and record keeping.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance. However, we identified opportunities for improvement related to the systems and processes for the receipt, distribution and recording of associated action for safety alerts.
- Staff had been trained to provide services with the skills, knowledge and experience to deliver effective care and treatment.
- 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 delivered at the practice was available.
- There was limited information available to communicate the complaints process to patients and associated records did not detail sufficient information to demonstrate improvements made as a result of complaints, concerns and incidents had been effective.
- Patients said they found it generally easy to make an appointment with a 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.
The areas where the provider must make improvements are:
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Ensure the arrangements, actions and records for identifying, recording, mitigating and managing risks to patient and staff safety are comprehensive and complete. For example:
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Ensure supporting systems for the management of clinical waste, single use items, blank prescription forms and refrigerator temperatures are effective.
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Ensure the outcomes of risk management activity are considered in a timely manner and appropriate action is taken to mitigate the risks identified.
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In addition the provider should:
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Consider the formal monitoring of cleaning activity within the practice.
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Consider the development of a system that includes the maintenance of associated records to demonstrate the effective management of safety alerts.
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Take action to improve the records of concerns, complaints and incidents to support effective communication and learning.
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Review information made available to patients related to the submission of complaints to ensure it is adequate and consistent with recognised guidance and contractual obligations for GPs in England.
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Consider the development and maintenance of records to demonstrate appropriate action is taken as a result of infection prevention and control audit activity.
- Implement comprehensive recruitment processes when employing any future staff.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice