Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Devonshire Green Medical Centre and the branch site at Hanover Medical Centre on 9 November 2016. The overall rating for the practice was requires improvement with requires improvement in safe and well led. The full comprehensive report from 9 November 2016 can be found by selecting the ‘all reports’ link for Devonshire Green Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified at our previous inspection on 9 November 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated good. Specifically, following the focused inspection we found the practice to be rated good for being safe and well led.

Our key findings were as follows:

• Recruitment checks to ensure staff were of good character had been completed. All clinical staff and staff who performed chaperone duties had received a Disclosure and Barring Service (DBS) check and there were references on file for new staff recruited since the last inspection.
• All staff had received safeguarding training relevant to their role as recommended in the Safeguarding Children and Young people: Roles and Competencies for Healthcare Staff 2014.
• All staff had received basic life support training as recommended in the Resuscitation Council (UK) Guidelines for staff working in a primary care organisation.
• The fire risk assessment had been reviewed. A fire drill had been carried out at both sites and maintenance checks of the fire alarm system were more regular although did not comply with the practice's Fire Safety Policy of being completed weekly at the Hanover Medical Centre site. These had been completed weekly at the Devonshire Green site.
• The legionella risk assessment had been reviewed and actions taken to mitigate the risks identified.
• A process to action safety alerts received by the practice had been implemented. However, there was no monitoring overview of these.
• A training matrix had been implemented to monitor what training staff had received and when it was due to be updated.
• .A system to monitor that clinical staffs’ registration with their professional body and medical indemnity cover for clinical staff was adequate and in date had been implemented.
• Cleaning schedules had been implemented to monitor what cleaning had taken place and the frequency.

Areas the practice should improve:

• The practice should implement a central log or monitoring overview of safety alerts received and action taken for staff to reference.
• The practice should carry out maintenance checks  in line with the Fire Safety Policy.

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 Devonshire Green Medical Centre and the branch site at Hanover Medical Centre on 9 November 2016. Overall the practice is rated as requires improvement.

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

• There was a system in place for reporting and recording significant events.
• Some risks to patients were assessed although shortfalls were identified with regards to recruitment checks, review of risk assessments such as fire and legionella, there was no record of fire drills and a lack of cleaning schedules.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff told us they had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment although there was no overview or monitoring by the provider of what training staff had received or when it was due.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Although information about the complaints process was not displayed, we saw that a leaflet was available behind the reception desk to help patients understand the complaints system.
• Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an urgent appointment at the daily drop in clinic. The next routine GP appointment was seen to be in two weeks’ time.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

• There was a leadership structure in place and staff told us they 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 areas of outstanding practice:

• The practice participated in an outreach clinic at the salvation army hostel and at the Cathedral Archer Project drop in centre one day a week. This enabled the GPs to encourage patients to engage in primary medical care, to promote better chronic disease management and health promotion, provide easy access and opportunistic screening to homeless patients. The practice also offered drop in clinics daily at both sites to support the homeless patients who were registered at the practice to access services.

• The practice had employed its own Somali link worker to support and assist patients. The link worker would assist with interpretation and had an advocacy role liaising with the local Somali community. We were told she would assist patients in reception when booking appointments and would assist patients to interpret letters.

The areas where the provider must make improvement are:

• Ensure all clinical staff employed since the practice registered with CQC have a Disclosure and Barring Service (DBS) check in place and ensure references for staff recruited are obtained and a record kept.

• Ensure all staff receive safeguarding training as recommended in the Intercollegiate Document, March 2014.

• Ensure all staff receive basic life support training as recommended in the Resuscitation Council (UK) Guidelines for staff working in a primary care organisation.

• Complete a review of the Fire risk assessment and follow the practice’s own Fire Safety Policy by implementing a system for fire alarm maintenance testing and fire drills and keep documentation of this.

• Ensure the Legionella risk assessment is reviewed and the actions in place are appropriate to mitigate the risks identified.

• Ensure a system is implemented to monitor what training staff have received and when it is due.

• Ensure there is a system to monitor clinical staff are registered with their professional body and medical indemnity cover is in place, appropriate and renewed for clinical staff.

• Implement a system to ensure safety alerts received by the practice are actioned and monitored.

• Ensure there are cleaning schedules in place to monitor what cleaning has taken place and when.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice