Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 3 March 2016. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12.

We undertook a focussed inspection on 18 October 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements. You can read the last comprehensive inspection report from March 2016 by selecting the ‘all reports’ link for Market Harborough Medical Centre on our website at www.cqc.co.uk

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• The practice had improved the governance framework in place to support the delivery of the strategy and good quality care. For example, systems for assessing and monitoring risks and the quality of the service provision.

• There was strong leadership within the dispensary and we saw evidence of safe and effective systems and processes in place

The areas where the provider should make improvements are:

• Continue to embed the new system for significant events and ensure meeting minutes include discussions and decisions made.

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 Market Harborough Medical Centre on 3 March 2016. Overall the practice is rated as requires improvement.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not thorough enough. On the inspection we saw evidence that the practice had just commenced a new system for significant events which will ensure that patients are kept safe.
• Risks to patients were assessed and well managed, with the exception of those relating to legionella water checks.
• Some systems and processes with the dispensary were not robust.
• 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
• Urgent appointments were available on the day they were requested.
• Prescription pads and blank prescription forms for use on the practice printers were not tracked through the practice.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had a number of policies and procedures to govern activity.
• The practice had proactively sought feedback from patients and had an active patient participation group.

The areas where the provider must make improvements are:

• Ensure there is adequate leadership in the dispensary and systems and processes in the dispensary are robust.

• Ensure there is a robust process for the handling of repeat prescriptions and repeat prescriptions are signed by a GP before medicines are dispensed to a patient.

• Take action to address identified concerns with infection control practice. For example, update training for infection control lead and attendance at link meetings, cleaning schedules for equipment and documentation for cleaning spot checks.
• Ensure there is a robust process in place for the blank prescription forms for use in printers and hand written prescriptions pads to be tracked through the practice.

In addition the provider should:

• Ensure that the new system for the reporting, recording and investigation of significant events is embedded and ensure that people affected receive reasonable support and a verbal and written apology.

• Put a system in place to ensure near miss errors in the dispensary are recorded and investigated.

• Undertake regular legionella water checks as identified in the legionella risk assessment.
• Undertake a further risk assessment for the storage of emergency equipment and medicines required for emergency situations to ensure the safety of patients and ensure they are responded to in a timely manner.
• Embed a process to ensure staff training is monitored.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice