Windmill Medical Practice Also known as Windmill Medical Practice

We carried out an announced inspection at Windmill Medical Practice on 28 June 2022. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

This was the first inspection of this practice following a change in their registration with CQC. Following our inspection under the previous registration on 4 November 2015, the practice was rated Outstanding Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Windmill Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection following a change in the provider’s registration with CQC.

We looked at all five key questions we usually look at when carrying out a comprehensive inspection.

How we carried out the inspection

Throughout the pandemic 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 using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A short site visit

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.

We have rated this practice as Good overall

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm. However there were some deficiencies in the care of patients prescribed a high risk medicine and gaps in fire risk assessments and sepsis training.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We found one breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

Whilst these were not a breach of regulations, the provider should:

• Review and improve the management of test results to ensure those actioned were archived appropriately.
• Review and improve performance in childhood immunisations and cervical screening.
• Continue to review findings of infection control audits to ensure recommendations are followed up on.
• Review and improve quality improvement activity to ensure a structured and regular programme.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services