Letter from the Chief Inspector of General Practice
This practice is rated as Good overall. (Previous inspection in January 2016 rated the service as Good overall).
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people living with dementia) - Good
We carried out an announced comprehensive inspection at Wombwell Medical Centre on 11 December 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider continues to meet the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
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 had clearly defined and embedded systems, processes and practices to minimise risks to patient safety.
- 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.
- Clinical audits demonstrated quality improvement.
- There was evidence of appraisals and personal development plans for all staff.
- Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.
- 79 out of 83 patient Care Quality Commission comment cards we received were positive about the service experienced. This is in line with the results of the NHS Friends and Family Test and other feedback received by the practice.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Staff worked together and with other health and social care professionals to deliver effective care and treatment.
- The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
We saw two areas of outstanding practice:
- The practice organised a ‘tea party’ in collaboration with Barnsley Independent Alzheimer’s and Dementia Support, South Yorkshire Dementia Alliance, and South Yorkshire Housing Dementia support for all patients and carers. This event covered fire safety and all patients were offered a home visit for assessments and improvements. All families and carers were supported to complete a Herbert protocol for all patients. (The Herbert Protocol is a national scheme being introduced by the Met in partnership with other agencies which encourages carers to compile useful information which could be used in the event of a vulnerable person going missing.)
- The practice had developed a protocol to ensure secondary care and community services were informed of patient deaths. This was to prevent further mail for the patient being sent out.
The areas where the provider should make improvements are:
- The provider should review the processes to ensure the competencies of the advanced nurse practitioners clinical decision making skills and non-medical prescribing.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice