6 January 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at St Peter’s Medical Centre on 6 January 2015.
Overall the practice is rated as Requires Improvement.
Specifically, we found the practice inadequate for providing safe care. It was requires improvement for the responsive and well-led domains. Required Improvement for providing services for all the population groups, It was good for providing effective and caring services.
Our key findings across all the areas we inspected were as follows:
- Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
- Patients said service received was good. Receptionists were friendly and helpful
- Immunisation rates were 96% and above the Clinical Commissioning Group (CCG) average.
- Data showed patient outcomes were average for the locality within the CCG.
- Some clinical audits had been carried out but we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
- In the July 2014 national GP patient survey 81% patients described the overall experience as good which was average for the CCG.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
- The practice had not proactively sought feedback from staff or patients.
The areas where the provider must make improvements are:
- Implement effective systems for the management of risks to patients and others against inappropriate or unsafe care. This should include the checking of medical equipment, fridge temperatures and disclosure and barring for staff recruitment.
- Identify, assess and manage risks relating to the health, welfare and safety of patients, staff and other people who may be at risk within the practice. For example, risk assessments for, legionella, oxygen, general office environment, control of substances hazardous to health (COSHH), use of a chaperone and infection control.
- Regard should be made to information available and patient views in delivering services and driving improvements.
- Ensure its recruitment arrangements and necessary employment checks are in place for all staff.
- Ensure that staff have appropriate support, identified through a formal appraisal system to have the necessary training to enable them to deliver the care and work they carry out in the practice.
- Put in place an effective system to regularly assess and monitor the quality of the service provided by St Peter’s Medical Centre. For example, ensure staff have clear guidance and the practice manage and learn from significant events and complaints.
In addition the provider should
- The practice should have a patient participation group (PPG) in order for patients and the practice to work together to improve the service and improve the quality of care patients receive.
- The practice should have policies in place in areas relating to whistleblowing and legionella. to provide guidance and support to staff.
- Policies and procedures should be reviewed to ensure that they are reviewed, updated and do not contain contradictory information, for example, the chaperone protocol.
- Have a clear audit programme to improve the quality of patient outcomes.
- Identify and deliver training and awareness to staff so they can deliver care safely and to an appropriate standard, for example, chaperone and Mental Capacity Act 2005.
- Offer patients the opportunity to have an annual physical health check.
Where, as in this instance, a provider is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected no longer than six months after the initial rating is confirmed. If the provider is inadequate for more than one key question they will go straight into special measures.
If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for a key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice