We carried out an announced comprehensive inspection at KS Medical Centre Limited on 17 July 2017. The overall rating for the practice was good. However, within the key question responsive some areas were identified as ‘requires improvement’, as the practice was had received low responses related to accessibility of appointments in the GP survey July 2017 results.

This inspection was a focused desk based review carried out on 31 August 2018 to confirm the practice had carried out their plan to make improvements. This report covers our findings in relation to those requirements and any additional improvements made since our last inspection.

Overall, the practice is rated as good.

Our key findings were as follows:

• The practice has made improvements relating to access at the practice.

In addition, improvements had been made in the following areas we had recommended;

• The practice had made improvements with the patient participation group and where working with the CCG to establish a fully functional group.

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 KS Medical Centre Limited on 29 March 2016. The overall rating for the practice was requires improvement. The full comprehensive report can be found by selecting the KS Medical Centre Limited ‘all reports’ link for on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 17 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 in our previous inspection on 29 March 2016. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

Overall the practice is now 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 a system in place for reporting and recording significant events.

• The practice had clearly defined and embedded systems to minimise risks to patient safety.

• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.

• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.

• Patients we spoke with 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.

• 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 the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

• However results from the national GP patient survey showed patients had responded not so well on questions relating to compassion, dignity and respect.

The areas where the provider should make improvement are;

• Continue to address and improve patient satisfaction in areas identified as below average in the July 2017 GP patient survey.

• Continue to look at ways of maintaining an active patient participation group.

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 KS Medical Centre on 29 March 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 a system in place for reporting and recording significant events, although records of analysis and learning from significant events were limited in detail.
• Risks to patients were assessed and generally well-managed, apart from those relating to health and safety, infection control and recruitment checks.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they felt the practice offered a good service and staff were helpful, polite, caring, and treated them with dignity and respect.
• 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.
• 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.
• There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity but some of these required review.
• The practice did not have a programme of continuous audit to demonstrate quality improvement.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are;

• Take action to address identified concerns with health and safety and fire safety processes.
• Ensure that clinical waste stored inside and outside the practice is managed in accordance with national guidance.
• Ensure that Disclosure and Barring Service (DBS) checks are undertaken for all clinical staff including health care assistants.
• Ensure effective governance systems for assessing and monitoring the quality of service provision.
• Maintain a record of outcomes and learning from discussions at practice meetings. 

The areas where the provider should make improvement are;

• Establish a comprehensive recording system for the receipt, dissemination and response to safety alerts received by the practice.

• Ensure an effective system for recording and monitoring significant events, incidents and near misses.

• Implement a system to monitor and track prescription pads kept at the practice.
• Review cleaning schedule documentation to ensure that all cleaning tasks are recorded.
• Ensure that staff attend basic life support training at intervals in accordance with national guidance  and undertake infection control and fire safety training as part of a mandatory training programme.

• Ensure that all staff receive regular appraisals.

• Review the business continuity plan to ensure that all potential circumstances are included.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice