Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Arden House Medical Practice on 22 August 2016. The overall rating for the practice was good. Following the inspection the practice sent us an action plan to address a requirement that the provider was not meeting.

The inspection report dated 22 August 2016 can be found by selecting the ‘all reports’ link for

Arden House Medical Practice 

on our website at www.cqc.org.uk.

We carried out a desk based review of

Arden House Medical Practice 

on 31 January 2017, to confirm that the practice had completed their plan to meet the legal requirement we identified at our last inspection. This report covers our findings in relation to the requirement and improvements made.

Our key findings were as follows:

• The practice had completed their action plan and was now meeting the legal requirement.

• The arrangements for assessing and managing risks at the practice had been strengthened. 

• The practice had recently purchased a defibrillator. The equipment was kept at the surgery and would be easily accessible for staff to use in the event of a medical emergency.  All staff had received training on the use of the equipment. 

• A Legionella risk assessment was carried out on 21 October 2016 

  to identify the risk of exposure of legionella bacteria in the water system

  . An action plan and control measures were in place to eliminate and manage the risks identified in the assessment.

• The chaperone policy had been updated to include the training requirements for staff to undertake this role. All relevant staff who acted as chaperones had received appropriate training to ensure they understood their responsibilities.

• ​The infection control audit had been updated to include an action plan to complete following an audit. This would provide evidence of action taken to address any improvements identified as a result of an audit.

• The induction programme for new staff had been updated, to include all essential information to cover the scope of their work. C

  ompleted inductions were signed off by the employee and a relevant senior member of staff, to support that staff had received appropriate training t

  o carry out their role effectively

  .

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 at Arden House Medical Practice on 22 August 2016. Overall, the practice is rated as good.

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

• Patients overwhelmingly told us they received excellent care and were treated with compassion, dignity and respect. They also said they were involved in their care and decisions about their treatment. This was corroborated bythe outcomes of the latest national GP patient survey, friends and family test results, and CQC comment cards.
• There was an effective system in place for the reporting and recording of significant events. Learning was applied from events to enhance the delivery of safe care to patients.
• Clinicians kept themselves updated on new and revised guidance and discussed this at clinical meetings. Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• We saw evidence of an active programme of clinical audit that reviewed care and ensured actions were implemented to enhance outcomes for patients.
• The practice planned and co-ordinated patient care with the wider health and social care multi-disciplinary team to deliver effective and responsive care and keep vulnerable patients safe. Weekly meetings took place to discuss and review patients’ needs.
• The practice directly employed a part-time community matron and part-time care co-ordinator to facilitate the delivery of care to support patients in their own homes.
• The practice employed care co-ordinator held monthly meetings with the social worker to help integrate health and social care planning and provision to patients.
• The practice had an appraisal system in place and supported staff training and development. The practice team had the skills, knowledge and experience to deliver high quality care and treatment.
• Arrangements in place to assess and manage risk were not always sufficiently robust. For example, the practice did not have a defibrillator and had no risk assessment or written protocol to cover its absence. Whilst unused water outlets were regularly run, the practice had not undertaken a legionella risk assessment.
• Feedback from patients demonstrated that patients felt they had excellent access to GP appointments. This was supported by the results of national GP patient survey.
• Longer appointments were available for those patients with more complex needs, and there was greater flexibility in offering appointments for vulnerable patients such as those with a learning disability.
• The practice had good facilities and was well-equipped to treat patients and meet their needs. The premises were accessible for patients with impaired mobility.
• There was a clear leadership structure in place and the practice had a governance framework which supported the delivery of good quality care. Regular practice meetings occurred, and staff said that GPs and managers were approachable and always had time to talk with them.
• The partnership had a clear vision for the future of the service, and were engaged with their Clinical Commissioning Group (CCG) in order to progress this.
• The practice had an open and transparent approach when dealing with complaints. Information about how to complain was available, and improvements were made to the quality of care as a result of any complaints received.
• The practice did not have an active patient participation group (PPG) at the time of our inspection, but they were reviewing the potential to develop a virtual group. The practice was keen to receive patient feedback from a variety of sources, which they acted upon.

The areas where the provider must make improvements is:

• Ensure they are doing all that is reasonably practicable to mitigate risks; specifically the provider must ensure they take appropriate action to mitigate the risks identified in their recent defibrillator risk assessment taking account of national guidance.

The areas where the provider should make improvement are:

• Formalise their assessment of risk in relation to legionella.
• Review induction documentation for new starters and include evidence that all of the content has been covered and signed-off as completed.
• Review the training of staff who act as chaperones to ensure they are clear on their responsibilities.
• Ensure a documented action plan is in place following infection control audits, and that this is updated as actions are completed

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice