19 January 2017
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection of Bridgewater CHCFT The Willaston Surgery on 24 August 2016. The overall rating for the practice was Good. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Bridgewater CHCFT The Willaston Surgery on our website at www.cqc.org.uk.
This inspection was a desk-based review carried out on 19 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 24 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is rated as Good.
Our key findings were as follows:
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The provider had ensured the premises were safely maintained. Evidence of a satisfactory electrical wiring inspection had been made available.
The following improvements to the service had also been made:
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Evidence was provided to demonstrate that significant events were reviewed at practice level to enable patterns and trends to be identified and any appropriate action to be carried out.
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Further improvements had been made to the system for ensuring adult patients with depression were receiving a review at the recommended frequencies following a new diagnosis.
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A plan had been put in place to ensure all staff received training in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.
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The induction records for clinical and non-clinical staff and the GP locum pack had been reviewed to provide greater detail and to ensure staff were provided with the information they needed.
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The protocol for incoming correspondence had been reviewed to ensure clarity of what should be sent to the GPs for review and action.
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A planned programme of audits had been put in place.
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Information about how patients can make a complaint had been revised to include who complaints should be directed to at the practice.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice