The Care Quality Commission
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Archived: The Three Shires Medical Practice - Colerne Also known as Colerne Surgery

Overall: Good read more about inspection ratings

New Surgery, 35 High Street, Colerne, Chippenham, Wiltshire, SN14 8DD (01225) 742028

Provided and run by:
Three Shires Medical Practice

All Inspections

03 July 2018

During an inspection looking at part of the service

This practice is rated as Good overall.

The key questions at this inspection are rated as: Are services safe? – Good

When we visited The Three Shires Medical Practice  on 21 November 2017, to carry out a comprehensive inspection, we found the practice was not compliant with the regulation relating to safe care and treatment. Overall the practice was rated as Good. They were rated as good for providing effective, caring, responsive and well-led services, and requires improvement for providing safe services. The full report on the November 2017 inspection can be found by selecting the ‘all reports’ link for The Three Shires Medical Practice  on our website at www.cqc.org.uk.

This report covers the announced follow up focused inspection we carried out at The Three Shires Medical Practice  on 3 July 2018, to review the actions taken by the practice to improve the quality of care and to confirm that the practice was meeting legal requirements.

At this inspection we found:

  • The practice had commissioned an external consultant to carry out a fire risk assessment and had taken action to address the recommendations made in the report. For example, they had fitting new fire signage at all four sites and installed emergency lighting at the Marshfield and Colerne sites.
  • Each site had a premises folder which included an up to date fire log book which evidenced that evacuation drills and fire equipment tests had been carried out at the appropriate intervals.
  • The practice had reviewed their security arrangements and had taken a range of actions to improve their security. For example, key safes had been installed at all four locations, the vaccine fridges were routinely kept locked and the keys stored in the key safe, and new doors had been commissioned for the cabinets used to store the old style patients records.

The practice is now rated as good overall and for the five key questions.

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

21 November 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall.

We previously  inspected  all four locations of  The Three Shires Medical Practice  in June 2016 and rated them as good:

Pucklechurch Surgery        - Good

Colerne Surgery                  - Good

Marshfield Surgery              - Good

Wick Surgery                      - Good

 

The key questions for Three Shires Medical Practice -   Colerne   are rated as:

Are services safe?               - Requires Improvement

Are services effective?        - Good

Are services caring?            - Good

Are services responsive?   - Good

Are services well-led?         - Good

 

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups for are rated as:

 

Older People                                           - Good

People with long-term conditions            - Good

Families, children and young people      - Good

Working age people (including those recently retired and students              - Good

People whose circumstances may make them vulnerable                            - Good

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

 

We carried out an announced comprehensive inspection at The Three Shires Medical Practice on 21 November 2017 as part of our inspection programme. We visited all four locations at Pucklechurch, Colerne, Marshfield and Wick, which between them serve a single patient list. The practice is led and governed by a single management team who are responsible for all regulated activities across all four surgery locations.

At this inspection we found:

  • The practice had systems to manage risk so that safety incidents were less likely to happen. However, arrangements for fire safety were not effectively implemented at all four locations; and when incidents did happen, the practice arrangements to learn from them and improve their processes were not fully implemented.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it. We saw evidence of very positive feedback from patients.
  • There was a focus on continuous learning and improvement at all levels of the organisation. However, learning was not consistently shared across all four locations.
  • Arrangements for dispensing medicines at the practice kept patients safe. However, some aspects of security of medicines and prescription stationery should be reviewed.
  • The practice returned above average achievement under the Quality and Outcomes Framework (QOF is a system intended to improve the quality of general practice and reward good practice).
  • Evidence of improvement in the cohesion of practice management processes across a number of topics and across all four surgery locations. However, further improvement should be made to ensure fully co-ordinated management arrangements.

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

  • Ensure care and treatment is provided in a safe way to patients, in particular in relation to arrangements for fire safety.

The areas where the provider should make improvements are:

  • Review arrangements for the security of medicines at the Marshfield surgery in relation to the dispensary and vaccine fridges to reduce the risk of unauthorised access, including outside normal surgery opening hours.
  • Review arrangements for non-clinical incidents to ensure they are implemented effectively and consistently at all four Locations; and when incidents happen, the practice learns from them and improves their processes.
  • Review records of training to ensure all staff have an up to date record of training relevant to their role, including a consistent approach for sepsis.
  • Review arrangements to provide consistency in monitoring of Medicines and Healthcare products Regulatory Agency (MHRA) safety alerts, to ensure all have been received at all four locations and all actions have been completed and recorded.
  • Review arrangements for the security of the patient records and tracking of blank prescription stationery.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

11 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at each of the four surgeries that form The Three Shires Medical Practice over three consecutive days. We visited The Three Shires Medical Practice – Colerne on 11 June 2015. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should:

  • Consider the use of an effective infection control tool that covers all aspects of prevention and control of infection.
  • Implement a system to ensure a formal audit cycle is in place.
  • Develop a protocol for the completion of care plans so there is evidence of patient involvement and all areas of the plans are completed and reviewed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice