We carried out a review of the data available to us about Countesthorpe Health Centre 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 Countesthorpe Health Centre, you can give feedback on this service.
We carried out an announced comprehensive inspection of the practice on 29 June 2016. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12 and 19 of HSCA (Regulated Activities) Regulations 2014 .
We undertook a focussed inspection on 16 September 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements. You can read the last comprehensive inspection report from June 2016 by following the link http://www.cqc.org.uk/location/1-548150327 or selecting the ‘all reports’ link for Countesthorpe Health Centre on our website at www.cqc.co.uk
At this inspection we found that:
There was now an effective system in place to ensure that relevant training was undertaken and kept up to date.
The system for checking and acting on abnormal pathology results had been reviewed and the protocol updated to ensure the system was effective.
Outstanding actions identified in risk assessments and audits had been addressed.
The areas where the provider should make improvements are:
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Countesthorpe Health Centre on 29 June 2016. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
Although the practice was proactive in providing requested training, there was not a robust system in place to ensure that mandatory training was undertaken and kept up to date.
The practice did not have a robust system for checking and acting on abnormal pathology results.
Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Feedback from patients about their care was consistently positive.
The areas where the provider must make improvements are:
Ensure there is a robust system in place to ensure that relevant training is undertaken and kept up to date.
Have a robust system for checking and acting on abnormal pathology results.
Ensure all required outstanding actions from risk assessments and infection control audit are implemented.
The areas where the provider should make improvement are:
To improve the system for the identification of carers.
Ensure secondary thermometers are being used in vaccine refrigerators.
Chief Inspector of General Practice
During this inspection, we spoke with the assistant practice manager. We did not speak with patients using the service.
The provider had systems in place to protect patients, staff and visitors against the risks of unsafe or unsuitable premises. We found that an independent specialist company had carried out a Legionella risk assessment and water sampling. We found signs were displayed next to sinks warning of the risk of the hot water temperature. This meant that the provider had considered the risks relating to Legionella and the hot water temperatures.
Patients were generally positive about their experiences and told us reception staff were polite and helpful. One person stated (the doctor) 'Spoke to me like I was an idiot.' We ascertained the person was unhappy with his current treatment, and though as yet had not made a complaint, was in the process of doing so. We made the Registered Manager aware of the patients concerns and frustration.
Medicines and vaccines are stored and dispensed appropriately.
The provider had systems in place for monitoring the quality of service provision, the PPG are active and have developed a number of questionnaires which are distributed to patients on an annual basis.
We found one area for improvement was a risk assessments was required to reduce the potential of cross infection at the practice.