Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Rochdale Road Medical Centre on 22 November 2016. Overall the practice is rated as good.

The practice had been previously inspected on 5 November 2015. Following that inspection the practice was rated as requires improvement with the following domain ratings:

Safe – Requires Improvement

Effective – Requires improvement.

Caring – Good

Responsive – Requires improvement

Well Led – Requires Improvement

The practice provided us with an action plan detailing how they were going to make the required improvements.

The inspection on 22 November 2016 was to confirm the required actions had been completed and award a new rating if appropriate.

Following this re-inspection on 22 November 2016, our key findings across all the areas we inspected were as follows:

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• The practice had a systematic process of dealing with and monitoring updates and guidelines from the National Institute for Health and Care Excellence.(NICE)
• Feedback from patient surveys undertaken by the practice and CQC patient comment cards were consistently positive about the practice. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Information about services and how to complain was available and easy to understand. 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. The practice had submitted plans for an extension to the building which would enable them to offer more services from the surgery.
• 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 provider was aware of and complied with the requirements of the duty of candour.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Rochdale Road Medical Centre on 5 November 2015.

Overall the practice is rated as Requires Improvement.

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

• Staff understood and fulfilled their responsibilities to raise concerns and to report near misses.There was an effective system in place for reporting and recording significant events.
• Patients needs were assessed and care was planned and delivered although there was no systematic way of dealing with and monitoring updates and guidance from the National Institute for Health and Care Excellence (NICE).
• Patients we spoke to 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 we spoke to said they found it easy to make an appointment with a GP and that there was continuity of care, with urgent appointments available the same day but not necessarily with a GP of their choice.
• 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 provider was aware of and complied with the requirements of the Duty of Candour.
• The practice did not have a formal induction process and administration and nursing staff did not receive regular appraisals.
• The practice did not have an active patient participation group (PPG) and did not proactively seek patients views about improvements to the service.
• There were no formal arrangements in place to ensure the practice complied with the Disability Discrimination Act.
• There had been no training on the Mental Capacity Act or Deprivation of Liberty.
• The practice did not have a whistleblowing policy however one was provided at a later date.
• Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.
• There was no evidence that an infection control audit or legionella risk assessment had been carried out however an infection control audit was provided at a later date.

The areas where the provider must make improvement are:

• Ensure systems are in place to deal with safety alerts and all clinicians are kept up to date with national guidance.
• Ensure all nursing staff have regular appraisals and that GPs and all staff complete mandatory training and keep a comprehensive record of training
• Complete full cycles of audits and create a log of audits with review dates.
• Ensure that regular risk assessments and audits are carried out for infection control and legionella.

In addition the provider should

• Actively seek patient views through a patient participation group and patient survey,

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We reviewed the information available to us about Rochdale Road Medical Centre on 11 June 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.