Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Victoria Park Health Centre on 28 November 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Victoria Park Health Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 18 August 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 28 November 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:

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Safety alerts and alerts from the Medicines and Healthcare products Regulatory Agency (MHRA) were reviewed and cascaded to the appropriate persons. We saw evidence that alerts received were disseminated to relevant members of staff and actioned where required to do so.
• The practice maintained appropriate standards of cleanliness and hygiene. Regular IPC audits were undertaken and we saw evidence that action was taken to address any improvements identified as a result. The practice ensured that a deputy IPC lead was in place.
• We reviewed personnel files and found appropriate recruitment checks had been undertaken prior to employment. For example, proof of identification, evidence of satisfactory conduct in previous employments in the form of references, qualifications, registration with the appropriate professional body and the appropriate checks through the DBS.
• The practice’s computer system alerted GPs if a patient was also a carer. The practice had identified 66 patients as carers which represented less than 1% of the practice list. However, as the practice was a university health centre, the practice had a high population of young patients, primarily students which included overseas students. The practice told us this had contributed to the low number of patients identified as carers compared to the patient list size.

The areas where the provider should make improvement are:

• Continue to review the process and methods for the identification of carers.

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 Victoria Park Health Centre on 28 November 2016. Overall the practice is rated as requires improvement.

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

• There was a system in place for reporting and recording significant events however it was not been adhered to in all cases. Staff we spoke with told of us incidents that had occurred which had not been recorded and investigated as significant events.
• Reporting of significant events was inconsistent. We saw evidence that incidents were discussed in the morning meeting minutes however these were not always completed in line with policy on the reporting forms.
• Risks to patients were assessed and well managed.
• 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.

• Patient survey figures were mostly above average when compared with CCG and national averages.
• Comments about the practice and staff were wholly positive.
• 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. However we did not see that improvements were made to the quality of care as a result of complaints and concerns.

• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. We saw this to be the case on the day of inspection.

• The practice were unable to produce an infection control audit.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• The practice had a virtual patient reference group of 32 members and a further 852 patients subscribed to receive email information from the practice.

• The practice had a clear vision to deliver high quality care and promote good outcomes for patients.

• The practice had a range of on line services and text message services that was suitable for the needs of the practice population.
• There was evidence of quality improvement including clinical audit.

• Safety alerts and alerts from Medicines and Healthcare products Regulatory Agency (MHRA) were reviewed and cascaded to the appropriate persons. However, we saw no evidence the practice carried out reviews and completed searches on the patient record system to ensure action was taken against the alerts.

The areas where the provider must make improvements are

• Ensure infection control audit is completed and any actions identified are addressed.

• Ensure processes for reporting and recording significant events, incidents and near misses is adhered to including non-clinical incidents.

• Ensure process is in place for the management of patient safety alerts and an audit trail of action taken following the alerts, such as audits and searches completed.

• Ensure recruitment is in line with policy and references are recorded and interview records are retained.

The areas where the provider should make improvement are:

• Review process and methods for identification of carers and the system for recording this. To enable support and advice to be offered to those that require it.
• Review complaints process to include learning and actions taken to prevent reoccurrence and improve quality of care.
• Review recruitment to ensure this is in line with the practice policies and procedures.
• Review lead roles such as infection control to enable staff to deputise provide cover during periods of unplanned absence.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Victoria Park Health Centre is situated next to the campus of The University of Leicester. The practice is a purpose built health centre opened in August 2013. It is located adjacent to the main university campus. We visited the practice on 9 July 2014 as part of this inspection.

As part of the inspection we spoke to various groups this included patients, staff, Clinical Commissioning Group and the Local Area Team.

Patients received safe care. Learning from incidents took place to improve safety. Staff had received training in safeguarding and was aware of how to report any suspicion of abuse. Staff had been provided with training in medical emergencies. Patients were protected from avoidable harm.

The practice provided effective care and treatment that met patient needs. Clinical guidance was referred to and followed by staff.

The practice was caring; patients were treated with dignity, respect and compassion. Patients we spoke with told us that they felt very positively of their experiences and of the care and compassion offered by the staff, this was supported by items we read in the comment cards.

The practice was well led. There was strong and visible leadership with a good philosophy of care that was shared by all staff. There were effective governance procedures in place and a system of using information from patients and from records to monitor the effectiveness of the practice.

The practice was responsive to patient’s needs. Complaints were investigated and responded to and lessons were learned to improve practice

We looked at different population groups. These were older people; people with long-term conditions; mothers, babies, children and young people; the working-age population and those recently retired; people in vulnerable circumstances; and people with mental health problems.

Although only a small number of patient were older people home visits took place if necessary for patients in this population group. The practice was accessible for all patients. There was parking for people with disabilities there was level access, adapted toilets and a vertical lift.

Due to the make-up of the patient list there were few patients with long term conditions. The practice manager said that less than 100 patients were identified as having diabetes out of a patient list of over 18,000.

The practice ran a midwifery clinic every Friday; this was in addition to the usual GP monitoring of mothers, babies, children and young people.

The vast majority of patients supported by the practice were of working age and recently retired. The practice offered online services including ordering repeat medication.

People in vulnerable circumstances; due to make up of the practice there were currently no persons in this category registered at the practice. The practice had identified that there were less than 10 patients registered at the practice who had a learning disability. The practice manager said that those patients had a mild learning disability and their social needs were met by other providers

There was considerable demand, by patients, for mental health services at examination times at the university.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.