Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 8 July 2015. 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 and 19 of

HSCA (Regulated Activities) Regulations 2014

.

We undertook a focussed inspection on 13 July 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 the December 2015 by following the link

http://www.cqc.org.uk/location/1-544619317

or selecting the ‘all reports’ link for Rosemead Drive Surgery on our website at

www.cqc.co.uk

At this inspection we found that:

• The significant event system had been improved with a new policy and reporting form in place and a consistent approach. Investigations identified actions which were implemented and learning shared with all staff.

  The practice had introduced a process to ensure emergency equipment and medicines are checked as per the practice protocol.

• Medicine refrigerators were checked and reset on a daily basis.

• There was now an effective and consistent system in place for dealing with significant events including reporting and the dissemination of learning from recorded events.

• There was now a consistent system in place to ensure referrals were made in a timely manner and monitored.

• Systems and processes relating to infection control in line with national guidance were put in place, including

  actions from infection control audits being recorded and implemented.

• All necessary employment checks for staff were undertaken, including DBS checks.

• Formal governance arrangements were in place, including systems for assessing and monitoring risks, for example relating to legionella and fire safety arrangements.

• Staff had received an annual appraisal.

• Policies had been reviewed and updated, including the policies relating to safety alerts, safeguarding vulnerable adults and arrangements for dealing with emergencies.

The areas where the provider should make improvements are:

• Further embed the process which has been introduced to

  ensure emergency equipment, other equipment and medicines are checked as per the practice protocol.

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 Rosemead Drive Surgery on 8 July 2015. 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, not all identified events were reported and there was a lack of evidence of learning from reported incidents.
• Risks to patients were not always assessed and well managed, for example recruitment checks and risk assessments in relation to fire safety and legionella.

• There was a programme of continuous clinical audit which was used to monitor quality and to make improvements.

• The practice had a number of policies and procedures in place to govern activity, however some required more detail.

• The practice had sought feedback from patients by means of surveys and via a virtual patient participation group.
• 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 found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• There was a clear leadership structure and staff felt supported by management.

The areas where the provider must make improvements are:

• Ensure there is a robust and consistent system in place for dealing with significant events including reporting and the dissemination of learning from recorded events.

• To have in place a robust and consistent system to ensure referrals are made in a timely manner and monitored.

• Ensure appropriate systems and processes are in place relating to infection control in line with national guidance, including actions from infection control audits being recorded and implemented.
• Ensure all necessary employment checks for staff are undertaken, including DBS checks.
• Implement formal governance arrangements including systems for assessing and monitoring risks, for example relating to legionella and fire safety arrangements.

In addition the provider should:

• Ensure scheduled appraisals take place and the system for appraisal is maintained.
• Review and update procedures and guidance, including the policy relating to safety alerts, safeguarding vuylnerable adults policy and arrangements for dealing with emergencies.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Though we spoke with more than 25 patients, only two agreed to share their experiences and both identified positive outcomes. One patient said “The staff are good, Dr A (named) is very good at explaining.” Both patients confirmed they felt listened to, were given choices and felt involved in their care. Both confirmed they were advised regarding any treatment risks and benefits. One person explained “They (the staff) are very kind” and “sometimes they run behind with appointments, but not very often.”

We found improvements were needed in infection control, where we found inadequate cleaning of surfaces and inadequate storage of cleaning equipment. There was also inadequate storage of clinical waste awaiting disposal in an area open to the public.

We found there were no defibrillators in either of the surgeries, though best practice would denote these were available for use. A defibrillator is a lifesaving machine that gives the heart an electric shock in some cases of cardiac arrest or irregular heart rhythm.

We found a large number of out of date medicines at one surgery, though we found medicines and vaccines were stored and dispensed appropriately at both surgeries.

We found that improvements were also needed around the recruitment policies and procedures and systems for monitoring the quality of service provision, and information around the surgery contact telephone number.