Wordsworth Health Centre was recently inspected by the CQC. The full report will be published shortly.
Please see the feedback assessment below.
We carried out an announced assessment of Wordsworth Health Centre from 22 July 2024to 2 August 2024. We carried out this assessment to follow up the breaches of regulation12 (safe care and treatment), regulation 17 (good governance) and regulation 18 (staffing).The breaches were found in the last inspection which was carried out from December 2022to January 2023 where the practice was placed in special measures and rated inadequate overall and in the safe and well-led domain, requires improvement in the effective and responsive domain and good in the caring domain. This assessment reviewed the key questions for safe, effective, responsive, and well-led. During the assessment we found that: leaders had implemented new systems and processes to keep people safe. Improved systems were in place, for example, for the safe management of high-risk medicine, recruitment procedures and safeguarding. We found the practice introduced an effective system in place to oversee regular staff training. We saw evidence of formal clinical supervision for healthcare staff and patient needs were being appropriately met. The practice had systems in place to help patients who required assistance in using the service. However, results from the 2024 National GP Patient Survey showed low scores in patient satisfaction in their access to the practice. We found leaders had put together an action plan to work on renewing processes and structures. Leaders had improved their governance and oversight over the practice. Due to the improvements, we have found during this assessment we have removed the practice from special measures.
During this announced assessment, we looked at all the key questions in the safe, effective, responsive and well-led domains and followed up on the breaches identified in the previous inspection.
During this assessment we found improvements:
- From our clinical record searches and review of practice policies and audits, we saw that the practice had introduced an effective system in place to manage medicines management. This included the management of patients prescribed high-risk drugs and medicines pertaining to MHRA safety alerts.
- From our review of practice policies and procedures, review of safeguarding systems in place and conversations held with staff, we saw that the practice had introduced a safe system to address safeguarding. Safeguarding registers were regularly reviewed, and all staff had appropriate safeguarding training.
- We found the practice had made improvements to recruitment and staff training. The practice performed the necessary checks prior to the recruitment of staff, including collecting DBS checks, obtaining ID and references. We reviewed a sample of clinical and non-clinical staff files and found all staff completed their training in time.
- We found the practice demonstrated a safe system was in place to effectively manage staff immunisations.
- From our review of the practices’ significant events log, complaints log, their policy on handling significant events and conversations with staff, we found there were effective systems in place to manage significant events and complaints.
- We found the practice had introduced an effective system to manage practice policies and documents. Policies and documents were renewed, and we saw clear lines of responsibility and governance in the management of handling and renewing policies.
- We found that the practices’ policy on managing two-week wait referrals had been revised and a review of their failsafe log demonstrated they were following their processes appropriately.
- We found the practice had introduced a system in place to ensure there was adequate clinical supervision. The practices’ clinical supervision policy was revised, and we saw evidence of clinical supervision audits and clinical supervision notes for clinical staff.
- We found the practice had introduced an improved system regarding core specific training for clinical staff. We saw, for example, health care assistants completed Care Certificate standards training.
- We found the practice had an effective system in place to manage clinical protocols.
- However, results from the 2024 National GP Patient Survey showed low scores in patient satisfaction in their access to the practice. This survey found 33% of patients found it easy to get through to the practice on the phone with 59% of patients finding receptionists at the practice helpful.
Overall, we found improvements in the management and governance of the practice during this assessment. The beaches of regulation identified at the previous inspection had been met. As a result of this inspection I am confident that ratings will improve and that we will be removing the practice from special measures.