The Care Quality Commission
  • Doctor
  • GP practice

Middlewich Road Surgery

Overall: Good read more about inspection ratings

163 Middlewich Road, Northwich, Cheshire, CW9 7DB (01606) 544700

Provided and run by:
Middlewich Road Surgery

All Inspections

22 November 2023

During a routine inspection

We carried out an announced inspection at Middlewich Road Surgery on 22 November 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring – rating of good carried forward from previous inspection

Responsive - good

Well-led - requires improvement

Following our previous inspection on 30 June 2015, the practice was rated good overall and for all key questions but safe which was rated requires improvement. At a follow up inspection on 24 January 2017, the safe key question was rated good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Middlewich Road Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

We inspected the key questions safe, effective, responsive and well-led.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

Our findings

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 found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care however improvements to some systems were required.

We found one breach of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

  • Take action to ensure staff training is completed to meet requirements.
  • Complete all staff appraisals and in a formal and timely manner.
  • Put in place a written programme of quality improvement and audits to review clinical activity over time to include formal monitoring of consultations for non-medical prescribers.
  • Continue to monitor and improve the uptake of cervical screening.
  • Continue to monitor patient feedback regarding access to the service and take action where this indicates improvement required.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

24 January 2017

During a routine inspection

We carried out an announced comprehensive inspection at Middlewich Road Surgery on the 30 June 2015. The overall rating for the practice was good. The domain of safe required improvement. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for Middlewich Road Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 24 January 2017 to confirm that the practice had implemented their plan to improve some aspects of safety within the practice. This report covers our findings in relation to improvements made since our last inspection.

Our key findings were as follows:

  • The practice had addressed the issues identified during the previous inspection.

  • They had updated their guidance and review of their triage system.

  • They had arrangements are in place to ensure that prescriptions were held securely at all times to avoid unauthorised access.

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

30 June 2015

During a routine inspection

We carried out an announced comprehensive inspection at Middlewich surgery on 30 June 2015. Overall the practice is rated as good.

Our key findings were as follows:

  • Systems were in place to ensure incidents and significant events were identified, investigated and reported. Staff understood and fulfilled their responsibilities to raise concerns and to report incidents. Information had been regularly shared and disseminated amongst the whole staff team so that everyone had opportunities to learn from significant events however clinical meetings had only recently commenced for the whole team.
  • The practice proactively sought to educate their patients to manage their medical conditions and improve their lifestyles by having additional in house services such as a diabetic clinic.
  • The practice had signed up to a local CCG led service for patients with dementia to promote early diagnosis and intervention.
  • The practice made good use of a large amount of clinical audits where the clinical staff had taken various actions to promote better patient outcomes.
  • Staff had received training appropriate to their role however in-depth training would benefit staff that operated the triage system.
  • Patients spoke highly about the practice and its staff. They said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice implemented suggestions for improvements and made changes to the way it operated its phone systems to improve patient satisfaction as a consequence of feedback from patients. The practice sought to attract more members to their patient participation group (PPG).
  • Information about services and how to complain was available and easy to understand.
  • Urgent appointments were available on the same day.
  • 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.

Action the provider SHOULD take to improve:

  • The provider should review the current system in place to regularly assess and monitor the quality and safety of the triage service provided.
  • The provider should ensure that arrangements are in place to ensure that prescription pads are held securely at all times to avoid unauthorised access.

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice