Birdhurst Medical Practice in South Croydon is a Doctors/GP specialising in the provision of services relating to diagnostic and screening procedures, family planning services, maternity and midwifery services, services for everyone, surgical procedures and treatment of disease, disorder or injury. The last inspection date here was 8th February 2019
Birdhurst Medical Practice is managed by Birdhurst Medical Practice.
Contact Details:
Address:
Birdhurst Medical Practice 1 Birdhurst Avenue South Croydon CR2 7DX United Kingdom
We carried out an announced focused inspection at Birdhurst Medical Practice on 12 December 2018.
At this inspection we followed up on breaches of regulations identified at a previous inspection on 11 January 2018.
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 have rated this practice as good overall and good for all population groups.
We found that:
The practice had improved arrangements for identifying, managing and mitigating risks, and now had effective systems for checking emergency medical equipment, mitigating the risk of legionella, recruitment checks and ensuring that staff were appropriately trained.
Systems and processes for learning and improvement had been strengthened.
Whilst we found no breaches of regulations, the provider should:
Monitor the improved systems to ensure that they are operating as intended, including arrangements for recording full analysis and learning from significant events.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Letter from the Chief Inspector of General Practice
This practice is rated as Good overall. The practice was previously inspected on 25 October 2016 and rated requires improvement overall.
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? – Requires improvement
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
We carried out an announced comprehensive inspection at Birdhurst Medical Practice on 11 January 2018. The inspection was undertaken to follow up breaches of regulation identified at our previous comprehensive inspection undertaken on 25 October 2016. The practice was rated as requires improvement for key questions: Are Services Safe and Are services Well Led? Requirement notices were issued for regulation 12 and regulation 17 of the Health and Social Care act 2014 regulations as the practice did not have adequate systems and processes in place to ensure that risks associated with fire and infection control were mitigated, that action was being taken in response to patient safety alerts, that adequate recruitment checks had been completed for all staff and that all staff had completed recommended training.
At this inspection we found:
In most respects 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. There was a minor risk associated with legionella where the practice had not taken action to ensure that this had been mitigated consistently.
Care and treatment was delivered according to evidence- based guidelines. The practice routinely reviewed the effectiveness and appropriateness of the care it provided. However there was limited evidence of work which aimed to improve the quality of care provided to patients and evidence suggested that coding of patient on the practice’s clinical system could be improved.
Staff involved and treated patients with compassion, kindness, dignity and respect.
Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
Governance systems were not effective in some areas for instance formalised clinical meetings where clinical updates alerts and guidance were discussed were infrequent and significant event and complaints were not routinely discussed in practice meetings. There were some gaps in essential training for staff. Evidence of comprehensive checks for locum staff were not present for a locum GP whose file we reviewed. The lack of quality improvement work, inconsistencies around coding and failure to consistently take action to mitigate risks associated with legionella also indicated deficiencies in governance.
The areas where the provider must make improvements are:
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas where the provider should make improvements are:
Increase frequency of formalised clinical meetings
Consider formalising the system for communicating learning outcomes from significant events and complaints.
Consider ways to improve the uptake of childhood immunisations.
Consider ways to improve the identification of patients with caring responsibilities and offer appropriate support to these patients.
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Birdhurst Medical Practice on 25 October 2016. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. However, there was no evidence that the practice were taking action in response to national patient safety alerts.
Not all risks to patients were assessed or well managed. For instance we found that the practice had not implemented any of the recommendations from their last fire risk assessment, recruitment checks had not been done for all staff and arrangements to ensure the safe management of medicines and mitigate risks associated with infection control were not effective.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had received training to provide them with the clinical skills, knowledge and experience to deliver effective care and treatment. However, not all staff had completed fire, infection control and basic life support training in line with current guidelines.
Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns. Though we found that complaints did not always offer an apology where appropriate and did not contain information of external organisations that patients could contact if they were unhappy with the practice’s response.
Patients said they found it easy to make an appointment with a named GP and 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.
The practice leadership structure was not always clear as some staff were not aware of the practice’s safeguarding or infection control leads. Staff told us they felt supported by management. The practice proactively sought feedback from staff which it acted on but the practice did not have a patient participation group.
The provider was aware of and complied with the requirements of the duty of candour.
The areas where the provider must make improvement are:
Ensure that there are systems in place for ensuring that action is taken in response to patient safety alerts and that this is recorded.
Ensure that there are appropriate systems in place to mitigate against risks associated with fire and infection control.
Ensure that all staff have received appropriate essential training.
Ensure that effective systems are in place in respect of medicine management including monitoring systems for controlled drugs and prescription pads. Ensure that recruitment and monitoring procedures are effective.
The areas where the provider should make improvement are:
Continue to work on developing mechanisms to gather feedback from patients.
Put systems in place to improve the identification of and support offered to patients who act as carers or those who have suffered bereavement.
Review methods used to advertise chaperoning and translation services.
Review areas where exception reporting rates are higher than local and national averages to ensure that these are appropriate and take action if required to reduce the number patients exception reported.
Review complaints procedures and policies to ensure that they comply with current legislation and guidance and consider the appropriateness of responses.
Consider introducing formal business or strategic planning.
Review failsafe mechanisms in place for monitoring the temperature of vaccines.
Consider offering longer appointments for patients with learning disabilities or complex conditions.
Review patients to ensure that all those with Chronic Obstructive Pulmonary Disease are being identified.
During our inspection we spoke with the practice manager, the practices three fulltime General Practitioners (GP's), and a nurse. We also spoke with six patients who regularly used the practice and two of their relatives. They told us staff treated them with respect and that they had confidence in all the doctors and nurses they saw at the practice. One patient said, “The staff are absolutely amazing”. Another patient told us, “I called the practice today at the last minute and the receptionist who was very helpful got me an appointment straight away”. Throughout our inspection we saw all the doctors, nurses and non-clinical reception staff that were on duty at the time interacted with patients and their representatives in a kind, respectful and helpful way.
It was evident from records we examined and feedback we received from patients and their representatives that they felt their privacy and dignity was respected by staff at the practice and were involved in discussions about their treatment options. We found patients received safe and appropriate treatment and support from suitably trained and experienced doctors, nurses and non-clinical staff (i.e.receptionists). The practice was kept hygienically clean and they had effective systems in place to routinely monitor and review the standard of care and treatment patients received. We also found patients had their comments and complaints listened too.
©2019 Care Services, all rights reserved. No part of this website may be reproduced without permission of the copyright holders.
