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

We carried out an announced comprehensive inspection at Windermere Medical Centre on the 3rd August 2016. Overall the practice is rated as ‘Good.’

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

• There was an open and transparent approach to reporting and recording significant events.

• Risks to patients were assessed and well managed for example, arrangements to safeguard vulnerable patients and keeping medicines safe.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

• Patients were positive about the practice and the staff team. They said they were treated with dignity and respect and felt involved in decisions about their treatment. Feedback from patients about their care was consistently positive.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.

• Information about services and how to complain was available and complaint records showed good responses to formal complaints.

• The practice had two buildings both single storey and one being a branch surgery. The branch surgery was in need of redecoration but was equipped to treat patients and meet their needs.

• The practice had strong and visible clinical and managerial leadership and governance arrangements. The practice had a clear vision with quality and safety as its top priority.

• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvements are:

Update the recruitment policy to include all required documents and checks as listed within the regulations.

To ensure the complaints policy includes details of the practice phone number to help patients choose how to raise their concerns.

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice