Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chobham and West End Medical Practice on 1 December 2015. The overall rating was good. During the inspection we found breaches of legal requirements and the provider was rated as requires improvement under the safe key question. Following this inspection the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:-

• Ensuring that all complaints and safety incidents and their investigation were recorded thoroughly and that learning was shared appropriately to support improvement.
• Ensuring that blank prescription forms were stored securely and tracked.
• Ensuring that clinical waste was stored securely.

The full comprehensive report on the 1 December 2015 inspection outcome can be found by selecting the ‘all reports’ link for Chobham and West End Medical Practice on our website at www.cqc.org.uk.

An announced focused inspection was carried out on 7 February 2017. This inspection was to verify if the practice had carried out their action plan to meet the legal requirements in relation to the breaches in regulations that we had identified in our previous inspection on 1 December 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

We saw that the practice had made significant improvements since our December 2015 inspection. Overall the practice is rated as good.

Our key findings were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting, recording and investigating significant events. Learning was shared with appropriate staff to support improvement.
• Blank prescription forms were being tracked and stored securely.
• Clinical waste was stored securely.

At our previous inspection on 1 December 2015, we found that the practice was performing below local and national averages for monitoring and reviewing patients experiencing poor mental health, uptake of flu vaccines and childhood immunisations We also noted that the practice was not maintaining a complete contemporaneous record for all patients.

During our inspection 7 February 2017 we saw;

• The practice was maintaining complete contemporaneous medical records for all patients.
• • The practice had a schedule in place to ensure regular reviews and monitoring of patients that were vulnerable or experiencing poor mental health.

The areas where the provider should make improvement are:

• Continue regular review of patient treatment outcomes to ensure increased uptake in childhood immunisations.

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 Chobham and West End Medical Practice on 1st December 2015. Overall the practice is rated as good.

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.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• 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.
• Patients said they could make urgent appointments on the same day.
• The practice had good 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.
• The provider was aware of and complied with the requirements of the Duty of Candour.

We saw one area of outstanding practice:

The practice had developed a single point access information resource which linked directly to all the practice policies and protocols, best practice guidelines and other external reference information. Many policies and protocols had hyperlinks allowing a single click to navigate between linked information. This resource was widely used by all staff.

The areas where the provider must make improvement are:

• Ensure that a robust system is put in place to ensure all significant events and complaints are recorded and investigated and that lessons learned from significant events and complaints are communicated to all appropriate staff to support continuous improvement.

• Ensure that prescription paper is stored securely.

• Ensure that clinical waste is stored in a safe and secure designated area.

The areas where the provider should make improvements are:

• Ensure that a complete medical record is kept for all patients.

• Ensure regular review of patient treatment outcomes to ensure increased uptake in flu vaccinations and childhood immunisations.

• Ensure regular review and monitoring of patients that are vulnerable or experiencing poor mental health.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

On the 18 February 2014 inspection we found the provider non-compliant in two regulations. Safeguarding people who use services from abuse and the requirements for workers. The provider sent us a report that set out the steps they would take to ensure they met the regulations. At this inspection we found the provider had taken all necessary steps and was now compliant in both areas.

At our previous inspection we noted staff had not received training in safeguarding vulnerable adults. At this inspection the practice manager informed us one of the GPs had taken on the lead role for safeguarding and had completed the necessary training. Training had been cascaded to staff and we saw evidence of staff attendance. Staff we spoke with had a good understanding as what constituted abuse and knew who to contact if they had any concerns. Staff told us they felt confident any concerns would be taken seriously by the provider.

The practice manager explained the process to ensure relevant information was obtained for new employees. This included a full employment history check with any gaps explored and suitable reference obtained. Photographic proof of identity was also requested and copies stored in recruitment files. The practice manager told us they would check if staff were physically and mentally fit to carry out their role. Where required proof of registration with a professional body was required and all staff completed a Disclosure and Barring Service check.

We did not speak to patients during this inspection.

During our inspection of Chobham and West End Medical Practice we spoke with seven staff, including a GP a nurse the Practice manager and reception staff. We also collected 25 responses to a survey questionnaire we left in the patient waiting area. Generally the responses we received from patients demonstrated a high level of satisfaction with the service they received at the practice. However a number of the responses referred the difficulties patients experienced getting an appointment with their own GP. Patients commented that they were treated with dignity and respect and that they felt involved in their treatment and that the care they received at the practice was good. One patient commented, ‘I am always given information and choices regarding my care.’

The practice had policies and procedures regarding safeguarding children and adults. We found however that whilst staff were aware of procedures around safeguarding children they were less sure about safeguarding vulnerable adults. Records showed that none of the staff had undertaken training regarding the protection of vulnerable adults. Patients surveyed commented they always felt safe with the staff at the practice. One person commented, ‘No I have never at any time felt unsafe nor had any concerns.’

We found that the practice had good processes in place to manage infection control. Patients commented that the surgery was clean. One patient commented, ‘It is a comfortable clean environment.’ Another person commented, ‘Excellent the surgery is always clean and tidy.’

Our review of recruitment files showed that staff recruitment practices were not robust. We found that some staff had not had the required checks undertaken prior to or since starting work at the practice.

There were procedures in place regarding complaints management and patients felt their complaints were dealt with appropriately and in a timely manner. One person commented, ‘I complained once and it was responded to quickly.’