The Care Quality Commission
  • Doctor
  • GP practice

Archived: Wellside Medical Centre

Overall: Good read more about inspection ratings

3 Burton Road, Derby, Derbyshire, DE1 1TH (01332) 737777

Provided and run by:
Wellside Medical Centre

All Inspections

1 November 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Wellside Medical Centre on 9 November 2016. The overall rating for the practice was good but it was rated as ‘requires improvement’ for providing safe services. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Wellside Medical Centre on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 1 November 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 9 November 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good

Our key findings were as follows:

  • The provider had amended their protocol for chaperoning and only those staff who had received a DBS check were able to provide this service for patients.
  • The provider had strengthened their processes for recording actions following safety and MRHA alerts. These were discussed at two-weekly clinical meetings to ensure all relevant staff knew of the actions required to address the alerts and provide an opportunity for learning.
  • The provider had implemented weekly meetings for reception and administration staff with the practice manager where actions and outcomes were recorded and accessible to staff. A member of staff from the reception and administration teams were also invited to each clinical meeting.
  • The partners had met to explore reasons for high exception reporting in respect of mental health disorders for 2015/16. They had increased the availability of clinical staff and flexibility of appointments offered and improved their recall system. This had resulted in more appointments being offered to patients and a reduction in exception reporting in four out of the six indicators for mental health disorders of between 10% and 17%. This was comparable to CCG and national averages.
  • The practice had recruited a new practice manager who was experienced in management within the NHS.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

9 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Wellside medical Practice on 19 July 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety within the practice. Effective systems were in place to report, record and learn from significant events. Learning was shared with staff and community staff at monthly meetings.
  • Most risks to patients were assessed and well managed. All recently recruited receptionists had received a DBS check, however, on the day we visited, there were some receptionists who had worked there for many years, who acted as a chaperone and had not received a DBS check. The practice informed us that a risk assessment was conducted immediately after our inspection.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Outcomes for patients were generally in line with local and national averages. However, exception reporting was significantly higher than CCG and national averages for QoF in some indicators.
  • The practice had implemented a process to make reviews easier for patients and more efficient by introducing a ‘Chronic Disease Annual Review’ recall system. This enabled many people with multiple conditions to be reviewed at one annual appointment.
  • Approximately 12% of the practice’s population were aged over 65, with 5% of these being over the age of 75. The practice had recognised the increasing support and input required to ensure the needs of this population group were met. For example; taking a multi-disciplinary approach to providing care and holding fortnightly meetings with the community matron and multi-disciplinary team.
  • The practice supported a women’s refuge and frequently provided care for women who had suddenly left their own homes/towns due to suffering from domestic abuse. The practice protected the confidentiality and safety of such patients by placing alerts on the system to ensure staff were aware not discuss any aspect of the patients details, unless a password was confirmed.
  • Training was provided for staff which equipped them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients told us they were able to get an appointment with a GP when they needed one, with urgent appointments available on the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. Services were designed to meet the needs of patients.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

The areas where the provider must make improvement are:

  • The practice should conduct a risk assessment for reception staff who act as chaperones and have not received a DBS check.

The areas where the provider should make improvement are:

  • The practice should consider implementing a formal meeting structure that includes reception and administration staff.
  • The practice should strengthen their record keeping, particularly in relation to following up on actions taken following a safety alert or MRHA alert, and ensure that staff follow the practice’s own protocol.
  • The provider should explore the reasons for high exception reporting in respect of mental health indicators and consider ways to reduce this to minimise risks to patient health and wellbeing

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice