Archived: Coalway Road Medical Practice

Letter from the Chief Inspector of General Practice

This practice is rated as Requires Improvement overall. (The practice was rated good at our previous inspection 27 May 2015)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

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 – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those recently retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) - Requires Improvement

We carried out an announced comprehensive inspection at Coalway Road Medical Practice on 11 December 2017. We carried out this inspection as part of our inspection programme.

At this inspection we found:

• The practice had some 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.

• There were areas where the practice did not have appropriate safety arrangements in place. This included:

  • The lack of systems to ensure all equipment was safely managed.

  • There was a lack of completed health and safety risk assessments and those in place were not regularly monitored and reviewed.

  • There was no evidence to confirm that appropriate arrangements were in place for the assessment of patients with presumed sepsis in line with NICE guidance.

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, not all staff had received up-to-date safety training appropriate to their role.
• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• The practice had a recruitment policy that set out the standards to be followed when recruiting clinical and non-clinical staff. However, these standards were not consistently maintained.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.
• Patients found the appointment system was not easy to use and reported that they experienced difficulty in accessing care when they needed it.
• There was a clear leadership structure and staff felt supported by management.

• There was focus on continuous learning and improvement.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

For further information, please see the Requirement Notices section at the end of this report.

The areas where the provider should make improvements are:

• Ensure an appropriate emergency pull cord is fitted in the patients disabled toilets to ensure their safety.
• Ensure that all equipment used at the practice are appropriately maintained to ensure they are safe to use.
• Ensure that the plans to improve the management of patients with diabetes and patients experiencing poor mental health including dementia, which include the completion of care plans, are implemented.
• Ensure that records are available to confirm that environmental risk assessments have been carried out.
• Review staff awareness of the requirements of the Mental Capacity Act (MCA) 2005 and ensure all staff are aware of their responsibilities under the Act as it relates to their role.
• Take a more active approach to identifying carers.
• Review the systems in place for the assessment of patients with presumed sepsis to ensure that they are in line with NICE guidance.
• Investigate the reasons for lower patient satisfaction in the GP national survey for patients experience in accessing appointments at the practice.
• Investigate the reasons for lower patient satisfaction in the GP national survey for patients experience with receptionists at the practice.
• Ensure that policies and procedures to support the effective operation of the practice are reviewed and updated.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice