This practice is rated as Good overall. (Previous inspection June 2017 – Good overall, with requires improvement rating for providing Safe services).

The key question is rated as:

Are services safe? – Good

We carried out a focused inspection at The Spires Health Centre on 1 June 2018. This inspection was in response to previous comprehensive inspection at the practice in June 2017, where breaches of the Health and Social Care Act 2008 were identified. You can read the report from our last comprehensive inspection on 29 June 2017; by selecting the 'all reports' link for The Spires Health Centre on our website at www.cqc.org.uk.

At this inspection we found:

The practice had reviewed their system for receiving and managing alerts including those from the Medical and Healthcare products Regulatory Agency (MHRA) and had strengthened their processes to ensure alerts were managed and actioned appropriately.

The practice had clear systems to manage risk so that safety incidents were less likely to happen. Since the last inspection the practice had completed a range of risk assessments to identify and manage risks appropriately. When incidents did happen, the practice learned from them and improved their processes.

• The practice had established processes to increase the identification of carers in order to provide further support where needed. This included staff training.
• A review of the induction programme had been completed to ensure new staff received training on infection prevention and control.
• A review of the complaints process had been completed to ensure verbal complaints were logged and discussed with the team and to monitor any trends through analysis. The practice also shared relevant complaints through a reporting incident web tool to the clinical commissioning group.
• The practice continued to try and encourage patients to join the patient participation group and had seen a small increase in patients expressing an interest. The practice had asked the CCG for advice on how to improve patient uptake and notices were on display in the waiting room encouraging patients to join and the date of the next meeting.
• The practice’s outcomes for national screening programmes continued to be low in comparison to national averages, however the practice was able to demonstrate how they monitored patients’ attendance for screening and they systems they had in place to follow up patients who did not attend.
• Since the last inspection the practice had reviewed their governance arrangements to ensure they were embedded within the team.
• The practice had implemented a prescription logging system to ensure all blank prescription pads were recorded before being used for home visits. The practice had also updated their prescription security protocol.

The areas where the provider should make improvements are:

• Continue to encourage patients to attend screening programmes.
• Continue to review the process to increase interest in 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 Spires Health Centre on 29 June 2017. Overall the practice is rated as Good.

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

• Although the practice had a system in place for receiving alerts from the Medical and Healthcare products Regulatory Agency (MHRA), we found some recent alerts had not been actioned. Since the inspection, we received evidence which showed that the practice had reviewed all alerts received since January 2017 and acted on each one appropriately.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events. Staff had regular meetings to discuss significant events and lessons learnt.
• The practice had systems to minimise risks to patient safety, but some were not effective. For example, health and safety risk assessments and fire risk assessments were not available on the day of inspection. Following the inspection, the practice providedevidence to confirm that these had been completed.
• We found blank prescription forms and pads were securely stored and there were systems to monitor their use within the practice. However, we found that there was no process to monitor the use of blank prescription pads during home visits. Since the inspection, we received a copy of an updated prescription security protocol.
• 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 and we were told all staff were receiving the appropriate training and updates for their role.
• Clinical audits demonstrated quality improvement and the practice carried out regular audits to monitor patient outcomes.
• Results from the most recent national GP patient survey published July 2016 showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their 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 and there was continuity of care.
• There was a clear leadership structure and staff felt supported by management. However, during the inspection we found that some governance arrangements were not established or effectivley operated. The practice proactively sought feedback from staff and patients, which it acted on.

However, there was an area of practice where the provider needs to make improvements.

The provider must:

• Ensure care and treatment is provided in a safe way to patients.

The provider should:

• Implement processes to ensure monitoring of prescription stationery
• Establish processes to increase the identification of carers in order to provide further support where needed.
• Log verbal complaints and consider as part of trend analysis.
• Review induction programme for new staff to ensure infection prevention is included.
• Ensure regular engagement with the practice patient participation group (PPG) to seek feedback from PPG members and patients

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice