The Care Quality Commission
  • Doctor
  • Out of hours GP service

Ilkley Moor Medical Practice

Overall: Good read more about inspection ratings

Springs Lane, Ilkley, LS29 8TH (01943) 604999

Provided and run by:
WACA Ltd

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Ilkley Moor Medical Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Ilkley Moor Medical Practice, you can give feedback on this service.

18 and 24 August 2021

During an inspection looking at part of the service

We carried out an announced focused inspection on 18 and 24 August 2021. This service is rated as good overall.

We reviewed and rated the following key questions as below:

Are services safe? – good

Are services effective? – good

Are services well-led? – good

Following our previous inspection on 29 November 2019, the provider was rated as requires improvement overall and requires improvement for providing safe and well led services. We issued a Requirement Notice for a breach of Regulation 17 – Good governance. The full report for the previous inspection on 29 November 2019 can be found by selecting the ‘all reports’ link for Ilkley Moor Medical Practice: WACA Ltd on our website at www.cqc.org.uk.

Why we carried out this inspection

This focused inspection was carried out to check that improvements had been made in respect of concerns and issues identified at our previous inspection. We inspected the key questions of safe, effective and well-led. The ratings in relation to caring and responsive are carried forward from the inspection undertaken in 2019 and remain good.

How we carried out the inspection

Throughout the pandemic the Care Quality Commission (CQC) has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews by telephone calls

• Requesting evidence from the provider

• Site visits.

As part of this inspection we interviewed by telephone; two nursing staff from different hub sites, one healthcare assistant (HCA), a physiotherapist and a pharmacist.

On the day of the inspection we interviewed the Registered Manager, a board director, three GPs working to deliver regulated activities, a reception team member, the business manager, social prescribing lead and the service administrator/ personal assistant.

We visited Townhead Surgery on 18 August 2021 as part of the inspection and spoke with the Registered Manager and the business manager on site.

Our findings:

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.

At this inspection we found:

  • The service had reviewed and improved their understanding of health and safety at all sites. This included an oversight of issues relating to fire safety and infection prevention and control.
  • The service had effective processes in place to assure themselves that staff who worked within the extended access service had the right knowledge, skills, competencies and training to carry out their roles, and were safe to do so.
  • The service had a system in place to report and respond to significant events. However, we did not see that these were consistently reviewed, with learning and changes shared with staff who were working to deliver regulated activities to ensure that such safety incidents were less likely to happen in the future.
  • Policies and procedures were reflective of the service and would direct staff to the best course of action when necessary. The provider was in the process of updating a small number of policies.
  • The service reviewed the needs and demographics of their patients in each hub location and ensured that care and treatment was delivered by the clinician who was best suited to support the patient and according to evidence- based guidelines.
  • Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
  • There was a renewed focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Take steps to share the policy for the effective management and response to safety alerts with all staff.
  • Provide staff with the opportunity to discuss and comment on their role within the extended access service during appraisals at their normal place of work.
  • Take action to ensure that the service recruitment procedure is followed and that appropriate checks are completed prior to new staff commencing employment.
  • Take steps to embed the recent changes made to the system for the reviewing and sharing of learning from incidents or significant events.
  • Take action to ensure that all clinical staff have adequate immunity for vaccine preventable infectious diseases.
  • Take action to ensure that staff working to deliver regulated activities are aware of the organisational leads such as the Freedom to speak up guardian.
  • Improve the documentation of meetings held to ensure they are reflective of the discussion and are available for staff review.
  • Act to formally notify the CQC of the decision taken to suspend the GP service at specific sites at weekends.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

21/11/2019

During a routine inspection

This service is rated as Requires Improvement overall.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at WACA (Wharfedale, Airedale and Craven Alliance) Limited on 21 November 2019 as part of our comprehensive inspection programme.

At this inspection we found:

  • Staff working at the service were able to access the patients’ own GP records to support continuity of care and the safe management of patients’ health needs. Information was relayed to patients’ own GPs in a timely manner, with appropriate follow up checks in place.
  • Patients were able to access care and treatment from the service within an appropriate timescale for their needs. Patient feedback about accessing the service was overwhelmingly positive. However, we were not assured that patients understood that the extended access service was offered by a different provider and not their own GP.
  • The provider liaised closely with partner agencies, commissioners and other key stakeholders to identify local need and plan future initiatives and services.

However, we also found that:

  • Arrangements for the dissemination of information and learning from significant events were not in place. A significant event policy was in place and these were discussed on an ‘ad hoc’ basis by the leadership team but were not shared with the staff who worked within the service.
  • The provider did not have systems and processes in place to maintain oversight of health and safety, fire, or infection prevention and control for staff or patients at the hub sites.
  • The provider did not have clear documented systems in place to monitor and maintain oversight of staff training, professional registration updates, staff vaccinations, indemnity insurance or disclosure and barring checks (DBS).
  • The provider did not directly communicate with staff working for them but relied on information to be disseminated by the practice managers of the hub sites at the staff members normal place of work.

The areas where the provider must make improvements as they are in breach of regulations are:

  • The provider must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Develop clear processes for blank prescription security at all sites where patients are seen.
  • Provide information in relation to making a complaint specifically for the extended hours service available to patients at all sites.
  • Improve their approach to the management and communication of significant events and evidence that these are actioned appropriately and any learning and changes are disseminated to staff working within the service.
  • Review the range of emergency medicines held on each site, ensure there is oversight of these and a rationale for any medicines not stocked at each location.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care