Background to this inspection
Updated
25 March 2019
Windermere Medical Centre is located at Windermere Avenue, Moss Bank, St Helens, WA11 7AG. The provider owns the premises. A branch surgery is also provided at Sandfield Medical Centre which is located at 61 Liverpool Road, St Helens, Merseyside, WA10 1PN. We visited both surgeries.
The practice works closely with St Helens Rota which is an out of hours GP service.
The practice is registered with the Care Quality Commission (CQC) to carry out the following regulated activities - diagnostic and screening procedures, treatment of disease, disorder or injury, surgical procedure; maternity and midwifery services and treatment of disease, disorder or injury.
The practice provides NHS services through a General Medical Services (GMS) contract to 3.096 patients. The practice is part of the St Helens Clinical Commissioning Group (CCG).
The practice’s clinical team comprises: the principal male GP who is also the provider; two regular locum GPs (both male); one female practice nurse prescriber and one female assistant practitioner. The practice has an advanced health practitioner (AHP) who is a non-registered health care assistant who has completed specialist training and qualifications to enable them to carry out specific clinical tasks. These tasks are completed under the close supervision of a suitably qualified and registered health care professional. The clinical team are supported by an established administrative team which included a full-time practice manager, reception manager and administrative and reception staff. The practice also worked closely with visiting nurse specialists such as the community diabetic nurse.
The service is provided at both practices each week day. The opening hours alternate each day and appointments are available 9am to 12mid-day and 3pm to 6.30pm Monday to Friday. Patients who have previously registered to do so may book appointments online. The provider can carry out home visits for patients whose health condition prevents them attending the surgery.
Extended hours are operated by St Helens Rota each Tuesday and Thursday evening until 6pm to 8pm and Saturday morning 9am to 9.30am.
An automated message signposts patient to the most appropriate service when the practice is closed.
There are an average number of patients in all age groups. Information published by Public Health England, rates the level of deprivation within the practice group as two, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest. Male life expectancy is 78 compared with the national average of 79. Female life expectancy is 82 compared with the national average of 83.
Updated
25 March 2019
We carried out an announced comprehensive inspection at Windermere Medical Centre on 6 February 2019 as part of our inspection programme.
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We have rated this practice as requires improvement overall.
We rated the practice as
requires improvement
in
providing safe services because:
-
The practice did not have formal systems in place to follow-up children who missed appointments. The provider did not attend any child protection meetings or updates.
- It was possible to identify looked after children by running a search and a specific list highlighting the vulnerable children and their families was held.
- The practice did not investigate significant events or other issues in sufficient depth when things went wrong.
- All the required health and safety risk assessments had not been completed.
We rated the practice as requires improvement in providing effective services because:
-
There was limited monitoring of the outcomes of care and treatment.
- The practice was unable to show that appropriate consent was always obtained prior to care and treatment.
We rated the practice as requires improvement in providing responsive care because:
-
The patients right to complain was not promoted in keeping with legal requirements for example information available about how to complain specifically stated that patients could only make complaints in writing.
-
Communication with the complainant did not include an unequivocal apology, information about possible learning from the event or information about how the patient could escalate the complaint if they were dissatisfied with the outcome of the investigation.
We rated the practice as requires improvement for providing well-led services because:
-
While the practice had a clear vision, that vision was not supported by a written strategy.
- The practice did not have clear and effective processes for managing risks.
- The systems and processes for learning, continuous improvement and innovation needed further development.
- The overall governance arrangements needed to improve and we noted managerial gaps in relation to medicines management; premises risk assessments, dealing with complaints and managing staff.
These areas affected all population groups so we rated all population groups as requires improvement.
We rated the practice as good for providing caring services because:
- Staff involved patients in decisions about their care.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
The areas where the provider must make improvements are:
- Ensure care and treatment is provided in a safe way to patients.
- Ensure that care and treatment of patients is only provided with the consent of the relevant person.
- Ensure care and treatment is provided in a safe way to patients.
- Ensure patients are protected from abuse and improper treatment.
- Ensure that any complaint received is investigated and proportionate action is taken in response to any failure identified by the complaint or investigation.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
-
Place photographs of staff on all staff files.
- Make sure all staff have completed the correct level of safeguarding training
- Provide formal fire marshal training to staff acting as fire marshals.
- Review the flooring in the clinical rooms considering best practice guidance.
- Make sure all blank prescriptions are securely stored and accounted for.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice