The Care Quality Commission
  • Doctor
  • GP practice

168 Medical Group

Overall: Good read more about inspection ratings

168 Locking Road, Weston Super Mare, Avon, BS23 3HQ (01934) 624242

Provided and run by:
168 Medical Group

Important: This service was previously registered at a different address - see old profile

All Inspections

During an assessment under our new approach

Date of assessment 25 April 2024 to 13 May 2024. 168 Medical Group is registered with CQC to deliver primary care services from a main surgery and a satellite surgery in Weston Super Mare. We conducted a responsive assessment to follow up on information of concern shared with CQC. We previously rated the practice as good. This assessment included 6 quality statements across the safe, effective, responsive, and well-led key questions. The practice demonstrated it had maintained areas of good practice and implemented a range of specialised processes and practices to support patients with complex needs, particularly in relation to mental health and dementia. The whole team had focus on health promotion and helping people live healthier lives. The practice had developed a range of innovative relationships and support services that reflected local health, economic, and social challenges. The practice had clear governance systems, many of which had recently been reviewed and updated during a change of leadership. However, we found areas for improvement in medicines optimisation. This included a need for more consistent ownership of key processes, such as accountability for documentation, and better nurse leadership, such as oversight of staff responsible for audits and monitoring.

During a routine inspection

This practice is rated as Good overall. (Previous inspection 17 February 2015 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at New Court Surgery on 26 September 2018 as part of our inspection programme.

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. They ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • There was a strong focus on continuous learning, mentorship and improvement at all levels of the organisation.
  • The practice had a mental health nurse who worked three days per week to provide regular support to patients with anxiety, depression and other mental health conditions.
  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. A programme of review of these was being carried out by the practice manager and the practice leads. For example, health and safety and medicines management.

The areas where the provider should make improvements are:

  • The provider should continue with a logging system for prescription paper that is fully in line with NHS England guidance.
  • The provider should continue with establishing the immunisation status of staff.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

17 February 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at New Court Surgery, Weston Super Mare on 17 February 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for the older people, children and families and young people, the working population, people in vulnerable circumstances and with long term conditions and people with mental health problems.

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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed by a skilled clinical team.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance with 7% of the most vulnerable patients being discussed at regular multidisciplinary meetings. 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. Their care and treatment was provided in a way which protected their privacy.
  • Information about services and how to complain was available but not promoted clearly in the waiting areas.
  • Patients 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.
  • The practice had modern, purpose built 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 several areas of outstanding practice including:

  • The practice had a clear and overarching view of vulnerable patients with 7% of patients registered with the practice having their needs routinely monitored during multi-disciplinary team meetings.
  • The practice had worked with the Clinical Commissioning Group (CCG) to implement a localised ‘Map of Medicine’ system of care pathways to ensure they consistently give the same level of care to patients across the CCG area. (The ‘Map of Medicine’ provides over 400 patient pathways, based on the most up to date research and clinical evidence available).
  • Where urgent home visits were required during normal appointment times the practice had a commissioning arrangement with the Out of Hours service for them to carry out the visit. This reduced the risks to patients in urgent need and prevented possible hospital admissions.

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

Importantly, the provider should:

  • Review how information is recorded on the significant events log.
  • Review how emergency medical equipment is stored and located.
  • Review the information available for patients on the practice noticeboards.
  • Review how information about the practices vision and values are shared with all staff and patients.
  • Review the frequency of fire evacuation testing to ensure the systems in place work as planned.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice