Chadsmoor Medical Practice

Updated 12 December 2016

Chadsmoor Medical Practice is registered with the Care Quality Commission (CQC) as a GP partnership provider in Chadsmoor, Cannock. The practice is part of the NHS Cannock Chase Clinical Commissioning Group. The practice holds a Personal Medical Services (PMS) contract with NHS England. A PMS contract is a locally agreed contract between NHS England and the general practice and offers variation in the range of service which may be provided by the practice. The practice area is one of higher deprivation when compared with the national and local Clinical Commissioning Group (CCG) area. At the time of our inspection there were 4,081 patients on the patient list.

The practice staffing comprises of:

• Two GP partners (one male and one female) and a female salaried GP.
• One part time nurse practitioner, two part time practice nurses and two part time phlebotomists (trained to take blood).
• A practice manager and reception staff.

The practice is open every weekday from 8.30am until 6.30pm, and the telephones are answered from 8am. Appointments are available every day except Thursday afternoons. Consultation times vary depending which GP is working, the earliest at 8.40am and the latest at 5.10pm. Extended hours appointments are available with the GPs on Tuesday evenings.

The practice does not provide an out-of-hours service to its own patients but has alternative arrangements for patients to be seen when the practice is closed through Staffordshire Doctors Urgent Care Limited, the GP out-of-hours service provider.

Updated 12 December 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Chadsmoor Medical Practice on 11 March 2016. A total of two breaches of legal requirements were found. After the comprehensive inspection, the practice was rated as requires improvement overall.

We issued requirement notices in relation to:

• Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014. Safe care and treatment.
• Regulation 17 HSCA (RA) Regulations 2014 Good governance.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Chadsmoor Medical Practice on our website at www.cqc.org.uk.

We undertook an announced comprehensive inspection on 27 October 2016 to check that the practice now met legal requirements.

Our key findings were as follows:

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients told us that they were able to get appointments when they needed them, with urgent appointments available the same day.
• The practice had made improvements to the process for recording, investigating and learning from incidents that may affect patient safety. An effective system had been introduced for reporting and recording significant events.
• The practice had introduced a governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
• Processes had been introduced to monitor the performance of the practice. This included significant events and complaints. Performance was discussed at the monthly practice meetings.
• Improvements had been made to the system for handling complaints and concerns. We saw that all complaints, both written and verbal, were recorded, investigated and responded to. Learning from complaints was shared with staff.
• The provider was aware of and complied with the requirements of the duty of candour.
• Risks to patients were assessed although the management in some areas needed to be improved. For example, servicing of the fire alarm and emergency lighting and addressing the recommendations in the legionella risk assessment.

There areas where the provider should make improvements are:

• Review all members of staff’s understanding of the role of a chaperone and where they should stand whilst the examination was taking place, to ensure they are following the practice policy.
• Move the cleaning mops to a more suitable storage area.
• Address the recommendations made in the legionella risk assessment.
• Carry out a fire drill which includes the evacuation of patients.
• Ensure the fire alarm and emergency lighting are serviced in line with the manufacturer’s guidance / current legislation.
• Provide fire marshal training for the designated member of staff.
• Provide information to patients about the availability of the translation service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 12 December 2016

The practice is rated as good for the care of people with long-term conditions.

• Nursing staff had lead roles in chronic disease management.

• The practice maintained registers of patients with long term conditions.

• Patients were offered a structured annual review to check their health and medicines needs were being met. The practice had introduced a structured system for inviting patients for their review or identifying patients who did not attend.
• Longer appointments and home visits were available when needed.
• For those patients with the most complex needs, the GPs worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 12 December 2016

The practice is rated as good for the care of families, children and young people.

• There were systems in place to identify and follow up children who were at risk, for example families with children in need or on children protection plans.
• Appointments were available outside of school hours and the premises were suitable for children and babies. Same day emergency appointments were available for children.
• There were screening and vaccination programmes in place and the practice’s immunisation rates were below the Clinical Commissioning Group averages. However, these had improved from the previous year’s rates.
• Data from the Quality and Outcomes Framework (QOF) for 2015/16 showed that 73% of women aged 25-64 had received a cervical screening test in the preceding five years. Although this was lower than the national average, it had improved from the previous year.

Updated 12 December 2016

The practice is rated as good for the care of older people.

• The practice offered proactive, personalised care to meet the needs of the older people in its population.
• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
• The practice participated in the hospital admission avoidance scheme. The care of these patients was proactively managed using care plans and there was a follow up procedure in place for discharge from hospital.

Updated 12 December 2016

The practice is rated as good for the care of working-age people (including those recently retired and students).

• The practice offered extended hours with the GPs on Tuesday evenings.
• The practice could book patients into the Cannock Network Project for appointments outside of normal opening hours.
• The practice was proactive in offering online services.
• The practice offered all patients aged 40 to 75 years old a health check with the nursing team.
• The practice offered a range of health promotion and screening that reflected the needs for this age group.

Updated 12 December 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

• The practice maintained registers of patients experiencing poor mental health, including those with dementia.
• There were 32 patients identified on the register for patients experiencing poor mental health and 29 of these had a care plan in place. These patients were offered an annual health check.
• The practice had identified 21 patients living with dementia and 19 of these had a care plan in place.
• The practice carried out advance care planning for patients with dementia.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

Updated 12 December 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability.

• The practice offered longer appointments for patients with a learning disability.
• The staff knew how to recognise signs of abuse in vulnerable adults and children. The staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.