Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 17 December 2015. Breaches of legal requirements were 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 17(1) Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this desk-based focussed inspection on 31 August 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Mitcham Medical Centre on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services.

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

Risks to patients were assessed and well-managed, including those related to recruitment checks and fire safety.

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 Mitcham Medical Centre on 17/12/2015. Overall the practice is 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 an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed with an exception of those relating to recruitment checks and fire safety.
• 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.
• 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 and complied with the requirements of the Duty of Candour.
• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group.

We saw one area of outstanding practice:

The practice worked closely with the local mosque to improve health in the local community for instance they had held a smoking cessation session at the mosque and had distributed leaflets in relevant languages.

However there were areas of practice where the provider must make improvements:

• Ensure suitable arrangements for staff to receive training to carry out their role and to have an annual appraisal of their work.

The areas where the provider should make improvements are:

• Ensure that the system for recording of significant events is robust and that the lessons learnt are shared with all staff.

• Ensure that action plans from audits, risk assessments, incidents and complaints are clearly documented and followed up.

• Ensure that a fire risk assessment and COSHH (Control of Substances Hazardous to Health) risk assessment and legionella risk assessment is completed.

• Ensure that patients on the practice’s learning disability register have access to annual health checks.

• Ensure that complaints are acknowledged and responded to in line with contractual requirements and a clear record of correspondence is kept.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice