We previously carried out an announced comprehensive inspection at Featherstone Family Health Centre on 16 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation identified in our previous inspection on 15 May 2017. We found some improvements had been made however, the practice remained rated as requires improvement for providing a safe service and requires improvement in well led.

This inspection was an announced comprehensive inspection carried out on to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation identified on 16 August 2017. The previous inspection reports can be found by selecting the ‘all reports’ link for Featherstone Family Health Centre on our website at

At this inspection, we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• 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.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Implement a more systematic approach to documenting serial numbers for both paper and electronic prescriptions.
• Consider guidance to support receptionists in the recognition of patient symptoms that may require emergency services such as the ‘red flag’ sepsis symptoms.
• Consider further improvements in documenting the learning from incident reporting.
• Consider staff training in the Mental Capacity Act and training to improve the use of electronic care plan templates.
• Implement changes to the practice complaint response document.
• Complete staff vaccination records to ensure these are all maintained in line with current Public Health England guidance and are relevant to their role.

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Featherstone Family Health Centre on 3 March 2015. The overall rating for the practice was good with requires improvement in providing a safe service. The practice was served Requirement Notices in Regulation 12, Safe Care and Treatment, of the Health and Social Care Act (Regulated Activity) Regulations 2014. The full comprehensive report on 3 March 2015 inspection can be found by selecting the ‘all reports’ link for Featherstone Family Health Centre on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 16 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation identified in our previous inspection on 3 March 2015. This report covers our findings in relation to those requirements.

We found the service had improved when we undertook a comprehensive follow up inspection on 16 August 2017. However, the practice remains rated as requires improvement for providing a safe service and requires improvement in well led.

Overall the practice is rated as requires improvement.

Our key findings were as follows:

• There was an inconsistent approach applied to reporting and recording significant events with no formal system in place to share learning from significant events and analysis of trends with staff to maximise learning and help mitigate further errors.

• Staff were aware of current evidence based guidance. The staff training logs were not up to date and some staff were overdue refresher training. The practice recognised prior to the inspection that there were gaps in staff training and planned staff training updates. The staff training log required management oversight.

• Patient monitoring of a specific high risk medicine had taken place for most patients however monitoring results had not been seen by a clinician prior to repeat prescribing.

• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.

• All appropriate recruitment checks prior to employment had not been completed for some staff.

• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.

• 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.

The areas where the provider must make improvement are:

Ensure care and treatment is provided in a safe way to patients in particular:

• Implement a formal system to share learning from significant events and analysis of trends with staff to maximise learning and help mitigate further errors.

• Ensure that fire safety training is provided to all staff from induction, staff members are in receipt of regular training updates and all staff attend fire drills.

• Introduce a process or system to be assured that appropriate actions are taken in response to medicine safety and devise alerts.

• Implement a formal system to ensure that appropriate monitoring takes place for all patients in receipt of high risk medicines.

• Ensure there are appropriate systems in place to manage staff training.

• Complete appropriate recruitment checks prior to commencement of employment, including references and, where appropriate, disclosure and barring checks (criminal record checks).

The areas where the provider should make improvement are:

• Safeguarding adults and children training and refresher training should be completed by all staff within the intervals recommended as best practice.

• Medicine dosage instructions stated the dose and frequency but needed a detailed and consistent formulation to be applied. For example, in one case reviewed the prescription noted the medicine dose in number of tablets and in another the medicine dose in number of milligrams.

• Infection prevention and control refresher training should be completed and documented.

• Policy and procedure revisions and updates should be completed.

• Consider documenting the practice strategy and business plan.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Specifically, we found the practice to be good for responsive, effective, caring and well led services. It was also good for providing services for older people, people with long term conditions, families, children and young people, the working age population and those recently retired, people in vulnerable circumstances and people experiencing poor mental health. It required improvement for providing safe services.

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. However, although information about safety was reported monitored and reviewed, records to demonstrate how issues were addressed were not consistently recorded.
• Risks to patients were assessed and well managed, with the exception of those relating to undertaking a legionella assessment of the premises.
• 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 that they found it easy to make an appointment with a named GP and urgent appointments were 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.

We saw two areas of outstanding practice:

• The practice actively engaged with two traveller communities who lived on designated traveller sites and promoted health screening by visiting them in the community. The practice offered them the opportunity to register as permanent or temporary patients.
• The practice worked closely with the local community and council to review the living arrangements of patients whose lack of a residence was having an increasing adverse effect on their health.

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

Action the provider must take to improve:

• Ensure that a legionella risk assessment of the premises is carried out and systems put in place to prevent, control, monitor and manage any risks identified.

Action the provider SHOULD take to improve:

• Ensure consistency in recording the analysis and outcome of investigations of safety incidents, significant events and complaints.
• Document health and safety assessments to demonstrate whether any specific risks related to the practice have been identified, appropriate action taken and risk assessments put in place to mitigate the risk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We reviewed the information available to us about Featherstone Family Health Centre on 2 May 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.