Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Elizabeth’s Medical Centre on 21 July 2016. The overall rating for the practice was good and the rating for the safe domain was requires improvement. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for St Elizabeth’s Medical Centre on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 31 January 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 21 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• An electrical safety installation check was carried out on 18 August 2016.

• A disaster handling and business continuity plan had been implemented to guide staff in the event of a major incident.

• The practice had carried out risk assessments as they did not have a defibrillator or oxygen available on the premises.

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 St Elizabeth’s Medical Centre on 21 July 2016. Overall the practice is rated as good.

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

• There was an effective system in place for reporting and recording significant events.

• Lessons were shared to make sure action was taken to improve safety in the practice.

• Most risks to patients were assessed and managed, however the practice had not carried out an electrical installation safety check.

• There were limited arrangements in place to deal with medical emergencies and major disruptions to the service.

• Data regarding patient outcomes were monitored on a regular basis and care plans were adjusted accordingly.

• Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

• Staff were aware of and understood their responsibilities under the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS).

• Patients told us they felt involved in decision making about the care and treatment they received. They also told us they felt listened to and had time to discuss their concerns

• Patients told us that they were able to get appointments when they needed them, including on the same day for an urgent appointment, and were satisfied with the opening hours.

• The practice had a system in place to ensure home visits were carried out effectively and efficiently.

• The practice had specific values to provide high quality care and promote good outcomes for patients. Staff were aware of the values and their responsibilities in relation to it.

• There was a governance framework which supported the delivery of good quality care. This included arrangements to monitor and improve quality and identify risk, although not all risks had been identified.

• The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty.

• The practice sought feedback from staff and patients, which it acted on.

The areas where the provider must make improvement are:

• Ensure all appropriate arrangements are in place to deal with medical emergencies and major disruptions to the service, including relevant risk assessments.

• Ensure the premises are safe to use by carrying out appropriate safety checks in relation to the electrical installation.

The areas where the provider should make improvement are:

• Ensure clinical refresher training is carried out in a timely manner.

• Review national figures for exception reporting against practice data.

• Ensure continued review of prescribing data in line with local and national prescribing guidelines.

• Review the ongoing process to ensure all carers have been identified.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice