Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Windsor Medical Centre on 10 May 2017. The overall rating for the practice was good. However, the key question of Safe and the population group of Families, children and young people were both rated as requires improvement. The full comprehensive report on inspection can be found by selecting the ‘all reports’ link for Windsor Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 26 September 2017 to confirm that the practice had carried out the required improvements that we identified in our previous inspection on 10 May 2017.

This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is now rated as good for providing safe services and for the care provided for the population group of families, children and young people.

Our key findings were as follows:

• The practice had reviewed their systems and processes for checking expiry dates of medicines and consumables held within the practice and provided assurance they were effective.
• The practice had reviewed their policies and procedures on exception reporting.

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 of this practice on 13 January 2016 which was previously managed by a different provider. The previous provider was Dr Ajit Pratap Mehrotra.

We rated the practice as inadequate in three domains; safe, effective and well led. Caring and responsive were rated as good. The practice was placed into special measures.

You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Dr Ajit Pratap Mehrotra on our website at www.cqc.org.uk.

A new provider, Dr Mangipudi Jayashree was awarded a contract to provide regulated activities at the same location from 10 April 2017. The new provider changed the name of the practice to Windsor Medical Centre.

We undertook an announced comprehensive inspection of Windsor Medical Centre on 10 May 2017 to check that the practice had responded to the concerns which were identified during the inspection of 13 January 2016. The practice is now rated as good overall.

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

• Staff understood their responsibilities to raise concerns, and to report incidents and near misses.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Staff had the clinical skills, knowledge and experience to deliver effective care and treatment. All staff were up to date with mandatory training.
• Risks to patients were assessed and well managed. For example, health and safety and legionella risk assessments had been undertaken.
• Information about services and how to complain was available and easy to understand.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments 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.
• The provider was aware of and complied with the requirements of the Duty of Candour.
• The practice had established governance arrangements including systems for assessing and monitoring risks and the quality of the service provision. For example the practice had increased the number of audits. The practice had introduced processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.
• Records relating to people employed included information relevant to their employment in the role including their professional registration and indemnity. The practice ensured there was a process in place for undertaking disclosure and barring service checks (DBS) and assessed the different responsibilities and activities of staff to determine if they are eligible for a DBS check and to what level.
• The practice provided staff with appropriate up to date policies and guidance to carry out their roles in a safe and effective manner which were reflective of the requirements of the practice and local CCG.
• The practice securely maintained accurate, complete and contemporaneous patient records.
• The practice engaged with the CCG medicines management team to audit prescribing. Inappropriate prescribing of some medications had been reduced in line with local guidelines.

The areas where the provider should make improvement are:

• Review their systems and process for checking expiry dates of medicines and consumables held within the practice to provide assurance they are effective.
• Review their policies and procedures around exception reporting, to reduce their exception reporting overall and to be assured that eligible patients are being encouraged to attend for screening.

I am taking this service out of special measures. This recognises the considerable improvements the new provider has made to significantly improve the quality of care provided. These improvements now need to become embedded in the practice and sustained, moving forwards.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice