21 March 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Melbourne Road Health Centre – R Kapur on 21 March 2016. Overall the practice is rated as requires improvement
Our key findings across all the areas we inspected were as follows:
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Data from the Quality and Outcomes Framework showed patient outcomes were above average for the locality and the national average.
- There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
- Not all risks to patients were assessed and well managed. The practice did not have a carpet cleaning schedule in place. Not all areas of the practice were cleaned in line with the practice cleaning schedule and guidelines.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with 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. Improvements were made to the quality of care as a result of complaints and concerns.
- The practice had a number of policies and procedures to govern activity.
- 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.
- 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 areas where the provider must make improvement are:
- Ensure appropriate systems and processes are in place relating to infection control in line with national guidance, ensuring consulting and treatment rooms are cleaned as per practice cleaning schedule and guidelines and implementation of carpet cleaning schedules.
- Ensure a suitable fire detection and alarm system is installed to ensure compliance with the action plan served by Leicestershire Fire Service (LFS). Ensure fire risk assessment is effective and all hazards are identified.
- Ensure the property is appropriately maintained and remedial repairs carried out to ensure the health and safety of staff, patients and visitors.
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Ensure procedures for monitoring and recording of water temperatures are in place, in line with the practice Legionella risk assessment.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice