The Care Quality Commission
  • Doctor
  • GP practice

Archived: Swanpool Medical Centre

Overall: Requires improvement read more about inspection ratings

St Marks Road, Tipton, West Midlands, DY4 0UB (0121) 557 2581

Provided and run by:
Dr Devanna Manivasagam

All Inspections

14 May 2021 to 21 May 2021

During a routine inspection

We carried out an announced inspection at Swanpool Medical Centre between 14 to 21 May 2021. Overall, the practice is rated as Requires Improvement.

The ratings for each key question were as follows:

Safe - Requires Improvement

Effective – Requires Improvement

Caring – Requires Improvement

Responsive - Good

Well-led – Requires Improvement

Following our previous inspection on 8 January 2020, the practice was rated Inadequate overall and for all key questions, except for providing caring and responsive services which were rated as requires improvement. The practice was placed into special measures. A GP Focused Inspection Pilot (GPFIP) between 14 September 2020 and the 2 October 2020 was also carried out to check what improvements had been made.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Swanpool Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on any breaches of regulations and ‘shoulds’ identified in the previous inspection.

How we carried out the inspection/review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A shortened site visit

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Requires Improvement overall and requires improvement for all population groups, except for families, children and young people, older people and people whose circumstances make them vulnerable which we have rated as good.

We found that:

  • The management of administration tasks needed improving. On reviewing the clinical system we found large numbers of tasks awaiting action and no management oversight was evident to ensure tasks were prioritised and acted on.
  • Some improvements had been made in the management and monitoring of patients’ clinical conditions. However, the practice had seen a significant decrease in the percentage of people with mental health and dementia with agreed care plans in the previous 12 months. Following the inspection, the practice provided unverified data for 2020/2021 which showed improvements in agreed care plans for people experiencing poor mental health and people with dementia.
  • On reviewing a random sample of patients records who had been prescribed an inhaler, we found formal reviews had not been completed and patients had been prescribed inhalers without the appropriate code on their records to identify them as having a condition that required this medicine.
  • Since the previous inspection the leadership team had reviewed the practice procedures and implemented effective processes to ensure staff training was monitored and staff completed training relevant to their role.
  • Processes had been implemented to ensure safeguarding registers were monitored and contained all the relevant information. Regular reviews of the registers were carried out and multi disciplinary meetings had been implemented to ensure information was shared effectively to protect patients from avoidable harm.
  • Risk management processes had improved and risk assessments had been completed to ensure the safety of staff and patients and to mitigate any future risks.
  • We found significant improvements in the management of patients’ care and treatment. on high risk medicines.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. This included individual risk assessments for staff, the use of personal protective equipment (PPE) and enhanced infection control procedures.
  • Governance arrangements had been strengthened to ensure risks to patients were considered, managed and mitigated appropriately.
  • The practice had implemented a system of peer review for the clinical team. On reviewing a sample of patient records we found prescribing decisions were in line with recognised guidance and consultations contained relevant information.

The areas where the provider must make improvements as they are in breach of regulations are:

• Regulation 17 HSCA (RA) Regulations 2014 Good governance

The areas where the provider should make improvements are:

  • Develop processes to encourage patients to attend cervical screening appointments.
  • Implement processes to encourage patients to attend childhood immunisation appointments.
  • Improve processes to ensure patients who had been prescribed inhalers have been coded and reviewed appropriately.
  • Implement stronger systems to ensure DNACPR information is recorded appropriately.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

N/A

During an inspection looking at part of the service

We carried out an unannounced comprehensive inspection at Swanpool Medical Centre on 8 January 2020, due to concerns identified at an inspection of the provider’s practice Clifton Medical Centre and its branch surgery on 19 December 2019. As there were concerns identified at a provider level, highlighting a lack of effective leadership and clinical oversight, a decision was made to inspect each of the providers (Dr Devanna Manivasagam’s) four practices on 8 January 2020. Following the inspection we took urgent enforcement actions against the provider and imposed conditions to their registration.

This GP Focused Inspection Pilot (GPFIP) in September 2020, was undertaken to follow up the conditions imposed on the providers registration with no site visit undertaken therefore was not rated

This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk in light of the Covid-19 pandemic. This was conducted with the consent of the provider. The inspection consisted of remote interviews and reviews of clinical records.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have not rated the practice during this inspection as we did not visit the Provider.

We found:

  • The practice was unable to demonstrate that there was clear oversight of governance arrangements to ensure risks to patients were considered, managed and mitigated appropriately.
  • On reviewing a random sample of clinical records, patient consultations had not always been undertaken in line with recommended guidance.
  • There was limited monitoring of the outcomes of care and treatment. Some clinical audits were available, however they did not demonstrate quality improvement or improved patient outcomes over a period of time.
  • Medication reviews had not been completed in line with recognised guidance. On reviewing a random sample of patients records, we found some patients had not received the appropriate monitoring before medicines had been prescribed.
  • The practice had implemented a system of peer review for the clinical team. We found on reviewing a sample of patient records that the system was ineffective as the performance of employed clinical staff could not be demonstrated through their prescribing decisions and reviews of their consultations.
  • The practice had safeguarding registers in place, however on reviewing the registers we found them to be inaccurate and not maintained appropriately.
  • The provider had strengthened the leadership team and had recently employed a new manager, GPs and nurse to strengthen the teams.
  • Staff training had been strengthened and a training matrix had been implemented to ensure all staff were up to date with training relevant to their role.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Continue taking action to improve the uptake of cervical screening appointments.

This service will remain in a period of extended special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

8 January 2020

During a routine inspection

We carried out a comprehensive unannounced inspection of Swanpool Medical Centre on 8 January 2020. We inspected Swanpool Medical Centre due to concerns identified at an inspection of Clifton Medical Centre and it’s branch surgery, Victoria Health Centre on 19 December 2019. As there were concerns identified at a provider level, highlighting a lack of effective leadership and clinical oversight, a decision was made to inspect each of the providers (Dr Devanna Manivasagam’s) services on 8 January 2020.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as inadequate overall and inadequate for all population groups in the Effective key question.

We rated the practice as inadequate for providing safe services because:

  • The practice did not have clear systems and processes to keep patients safe. We found safeguarding registers lacked information to advise staff of potential concerns.
  • The practice did not have appropriate systems in place for the safe management of medicines. We found out of date child vaccines being stored and no system in place to ensure out of date stock was disposed of appropriately.
  • Emergency medicines were available, however we found out of date adrenaline and syringes in one of the consulting rooms.
  • We found prescription stationery was not kept securely, with blank prescriptions left in printers in consulting rooms and the doors were left unlocked when not in use.
  • The practice were unable to demonstrate effective management of risks in relation to medicine safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA).
  • The practice was unable to demonstrate how they learnt or made improvements when things went wrong. There was no evidence available that actions had been taken and learning had been shared with staff to mitigate further risk.

We rated the practice as inadequate for providing well-led services because:

  • There was a leadership structure and some staff said they felt supported by management; however effective oversight to ensure governance arrangements were embedded had not been established. For example, Risk assessments had been completed, but the practice was unable to demonstrate that identified actions had been acted on.
  • Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care. The practice was unable to provide evidence of a vision and credible strategy to ensure quality care was provided. We found due to the lack of clinical and managerial leadership the practice had been unable to embed a strategy to improve patient outcomes.
  • We identified significant failings in the care of patients, this included: safeguarding concerns not being addressed, overall management of patients with long term conditions and a lack of clinical oversight to ensure patients were receiving adequate care and treatment.
  • There were arrangements for planning and monitoring the number of staff needed; however, there were no formal plans to reduce the reliance of locums to ensure continuity of care and clinical cover.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.

We rated the practice as inadequate for all population groups because:

  • The practice was unable to demonstrate that patients were monitored effectively. Due to the lack of clinical oversight at the practice, patients were not monitored or reviewed regularly.
  • Staff training and development was not monitored appropriately. The practice was unable to demonstrate that clinical staff had completed training relevant to their role.
  • On reviewing a sample of patients records we found clinical records had not been summarised and lacked information for clinical staff to make the appropriate assessments of patients’ needs.
  • Patients on high risk medicines were not monitored in line with recognised guidance. On reviewing a random sample of patients on these medicines we found regular tests had not been carried out before medicines had been prescribed.
  • We found patients’ whose blood tests had showed them being within the diabetic range had not been informed of their new diagnosis or followed up appropriately.
  • On reviewing a sample of patients records we found patients with diabetes had not been coded appropriately and were not referred for further monitoring or invited for reviews.
  • The practice had safeguarding registers in place, however on reviewing the registers we found them to be inaccurate and not maintained appropriately.
  • We found adults were listed on the child protection register and patients who should have been removed from the register continued to be active.
  • The practice had no register for patients who had undergone female genital mutilation (FGM). On doing a search of the clinical system, patients were identified, however there were no alerts on their clinical records to advise staff of potential safeguarding concerns.

We rated the practice as inadequate for providing effective services because:

  • There was limited monitoring of the outcomes of care and treatment. No clinical audits were available to demonstrate quality improvements had been reviewed and actioned.
  • The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles. We found limited evidence that staff had received regular reviews and appraisals. There was no evidence to demonstrate that staff were given opportunities for learning and development.
  • The practice did not routinely review the effectiveness and appropriateness of care provided. Care and treatment were not always delivered according to evidence-based guidelines. For example, patients identified as being within a diabetic range had not been informed or followed up appropriately.

We rated the practice as requires improvement for providing caring and responsive services because:

  • There was no evidence that complaints had been acted on and no minutes of meetings available.
  • The leadership team told us that the survey results were discussed at practice meetings; however, there was no evidence available to show action plans were in place to address areas where satisfaction was below local and national averages.
  • The practice was unable to demonstrate they had gathered feedback to monitor patient satisfaction.


The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue to encourage patients to attend cervical screening appointments.


I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

12 June 2019

During a routine inspection

We carried out an announced comprehensive inspection at Swanpool Medical Centre on 12 June 2019 as part of our inspection programme.

At the last inspection in August 2018 we rated the practice as requires improvement for providing safe and responsive services because:

  • The provider had insufficient governance arrangements in place concerning oversight of patient groups directions (PGDs).
  • Staff were not following cold-chain procedures.
  • The national patient survey revealed lower than average patient satisfaction relating to access to services.

At this inspection, we found that the provider had satisfactorily addressed most areas although further improvements were required relating to patient satisfaction on access to services.

We based our judgement of the quality of care at this service is on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as good for safe, effective, caring and well-led services. 

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We rated this practice as requires improvement for resposnsive services.

We found that:

  • Although the service was working to improve access, the national patient survey revealed lower than average patient satisfaction relating to access to services in some areas.

These areas affected all population groups, so we rated all population groups as requires improvement.

Whilst we found no breaches of regulations, the provider should:

  • Explore ways to identify themes and trends from complaints.
  • Continue to explore ways to improve telephone access.
  • Consider if the location of the call bell at the front entrance is accessible by all patients including those with a disability.
  • Continue to explore ways to improve screening uptake.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

13 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We previously carried out a comprehensive inspection at Swanpool Medical Centre on the 9 June 2015. The practice received an overall rating of requires improvement. We carried out a follow up comprehensive inspection on the 16 November 2016 to see if improvements had been made. The practice continued to be rated requires improvement overall with an inadequate rating for services being well led. The practice was issued with a warning notice in relation to regulation 17 good governance. The full comprehensive reports for both these inspections can be found by selecting the ‘all reports’ link for Swanpool Medical Centre on our website at www.cqc.org.uk.

This inspection was undertaken to follow up progress made by the practice since the inspection on 16 November 2017 and was an announced comprehensive inspection on 13 July 2017. Although we have seen improvements the practice continues to be rated as requires improvement overall.

Our key findings were as follows:

  • We found that significant improvements had been made to address concerns raised during our previous inspection. The practice was reliant on the use of locum GP and there had previously been little evidence of involvement of these GPs within the practice’s clinical governance arrangements including the sharing of best practice, management of incidents, safety alerts, complaints and learning from these.
  • At this inspection we found effective systems and regular clinical meetings had been put in place for disseminating and information sharing among all staff including locum GPs.
  • There had been improvements to the systems for reporting and recording significant events and to ensure learning from these. Staff were aware of their responsibilities.
  • Risks to patients were assessed and managed, we saw improvements in relation to infection control, the management of prescriptions, emergency medicines and equipment.
  • The practice was reliant on long term locum GPs to deliver the service. However, there were no contracts in place to clarify working arrangement or commitments.
  • There were improvements in the way in which best practice was shared and discussed among clinical staff to support the delivery of care.
  • Staff had been trained to provide them with the sills, knowledge and experience to deliver effective care and treatment.
  • Data showed the practice performed well in terms of patient outcomes overall. However, we identified palliative care as an area for improvement and to ensure patients received timely prescriptions.
  • Patient feedback received on the service was mixed. Data from the national GP patient survey was lower than local and national averages across most questions. Improvement was limited and in many areas was lower than the previous patient survey. Feedback from the CQC comment cards was positive overall.
  • Information about how to complain was available and easy to understand. Learning from complaints was shared.
  • The practice had good facilities and was equipped to treat patients and meet their needs. We saw that there had been some refurbishment of the premises since our previous inspection and better organised.
  • We saw improvements in the governance arrangements since our previous inspection. Policies and procedures were being reviewed and made practice specific. However, we were not fully assured that there was sufficient capacity to manage patient information received for timely action.
  • However, there were also areas of practice where the provider needs to make improvements.

In addition the provider should:

  • Consider adding alerts to patients, where appropriate who have direct links to a patient known to be at risk of harm.
  • Ensure appropriate sharps bins in place that reflect the needs of the practice.
  • Ensure appropriate coding of patients on high risk medicines so that they can be easily identified.
  • Ensure contingency arrangements for clinical cover are in place.
  • Maintain formal supervision records of support provided for the Advanced Nurse Practitioner.
  • Develop care plans to support patients in the management of their long term health conditions.
  • Continue to review patient feedback, including feedback from the national patient survey and identify how the service might be further improved.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

16 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Swanpool Medical Centre on 16 November 2016. The practice had previously been inspected in June 2015 and was found to be in breach of regulation 16 (complaints), regulation 17 (good governance) and regulation 19 (fit and proper persons employed). The practice was rated as requires improvement overall.

Following the previous inspection the practice sent us an action plan detailing the action they were going to take to improve. We returned to the practice to consider whether improvements had been made. We found the practice had made insufficient improvements to improve the service.

The breaches in relation to regulation 16 (complaints), regulation 19 (fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been addressed and the practice was now compliant with these regulations. However, the breaches in relation to regulation 17 (good governance) had not been fully met. We also identified additional breaches in relation to regulation 12 (Safe care and treatment).

The practice is rated as requires improvement.

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

  • The systems for reporting and recording significant events had not improved sufficiently since our previous inspection to support and improve safety in the practice. There was little evidence to show that clinical staff were involved in reporting and sharing incidents and their learning.
  • There had been some improvements in the management of risks since our previous inspection for example, those relating to staff recruitment and fire safety. However we found weaknesses in relation to infection control, prescription safety and the follow up of actions required from the legionella risk assessment.
  • Data showed patient outcomes were comparable to local and national averages in most areas.
  • There was little evidence that clinical audit was driving quality improvement in patient outcomes.
  • Staff had the skills, knowledge and experience to deliver care and treatment.
  • There was evidence of staff appraisals but these had not all been appropriately completed.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs however feedback received from community teams identified areas for improvement.
  • The majority of patients said they were treated with compassion, dignity and respect. However, not all felt cared for, supported and listened to.
  • We saw improvements in the management of complaints since our previous inspection. Information about services and how to complain was available and easy to understand and learning from complaints was shared at practice meetings.
  • Patients said they did not always find it easy to make an appointment. Changes had been made to the appointment systems which had led to improvements such as a reduction in the number of non attendances and increased use of the on-line booking system.
  • The practice was accessible to patients and equipped to treat patients and meet their needs.
  • Governance arrangements were not sufficiently effective to ensure all staff groups were involved in supporting the service to improve.

The areas where the provider must make improvement are:

  • The practice must improve governance arrangements for managing quality and safety.
  • Ensure effective systems are in place for all staff (including clinical staff) to be involved in reporting and learning from incidents and complaints; for discussing and sharing best practice guidance and clinical audit
  • Ensure safety alerts are consistently acted upon and for monitoring and acting on recommendations arising from risk assessments.
  • Review and implement effective practice specific policies and share with staff.
  • Ensure effective systems are in place for managing uncollected patient prescriptions.
  • Ensure effective systems for managing prescription stationery.
  • Ensure effective systems are in place for managing infection control within the practice.

The areas where the provider should make improvement are:

  • Check that the thermometer on the medicines fridge is operating correctly to ensure that vaccinations are stored in line with public health guidlines.
  • Review systems for managing equipment and medicines used in a medical emergency to ensure they can be accessed quickly with clear monitoring processes.
  • Review the effectiveness of staff appraisals to ensure staff have the opportunity to discuss any learning and development needs.
  • Review and develop effective multi-disciplinary working arrangements with the community teams.
  • Ensure patients with a learning disability receive the opportunity for an annual health review.
  • Continue to review patient feedback including feedback from the national patient survey and identify how the service might be improved.
  • Review and implement policies that are practice specific and support staff in the day to day running of the practice.
  • Review staff understanding and application of relevant consent and decision-making requirements for those who may lack capacity and children including the Mental Capacity Act 2005

Where a service 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 report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service 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

9 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Swanpool Medical Centre on 9 June 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe, effective, responsive and well led services and good for providing a caring service. It also required improvement for providing services for the six population groups (older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia). This is because the concerns that have led to the overall provider rating apply to everyone using the practice, including these population groups.

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

  • At the time of the inspection Swanpool Medical Practice was in a transitional phase following a recent merger of two former practices. The practice was reliant on locum GPs to provide the clinical services at the practice. The principal GP also ran three practices and was a salaried GP at a fourth practice. Within this context the main challenge has been to develop robust governance arrangements.
  • The provider had not correctly registered the practice with the Care Quality Commission. The practice was registered as a sole provider but at the inspection told us that the practice was a partnership.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded but did not always demonstrate clear learning which was shared among staff.
  • Risks to patients were assessed and managed, but assessments were not always robust including those relating to fire and staffing.
  • There was a lack of current published national data relating to patient outcomes due to the merger of the two former practices at Swanpool Medical Centre in June 2014 but early indications from practice data appeared to be showing good progress.
  • Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
  • Patient feedback about the service was mixed. Satisfaction with the service and quality of consultations was generally in line with the Clinical Commissioning Group (CCG) average but below the national average.
  • Information about services and how to complain was available but the practice did not operate a robust complaints system to ensure complaints were appropriately managed.
  • Patients had reported access to appointments was difficult and the practice had responded to this through increased sessions.
  • Governance arrangements were not robust to ensure important issues affecting the practice were routinely discussed with staff.
  • The practice had sought feedback from patients.

The areas where the provider must make improvements are:

  • Ensure robust governance arrangements are in place for the management of quality and safety. Including systems to ensure important information is routinely discussed and shared with staff and actions identified implemented to improve the service provided. This would include management of significant events, complaints, safety alerts, audits, best practice guidance and the management of risks relating to fire safety and staffing.
  • Ensure appropriate recruitment information is maintained for staff employed.
  • Ensure audits undertaken are full audit cycles to demonstrate improvements made and that the findings are shared to deliver those improvements.
  • Ensure a robust complaints process is in place which is consistently followed.

In addition the provider should:

  • Ensure systems are in place for maintaining an accurate audit trail for prescriptions.
  • Review arrangements to ensure patient dignity is not compromised in using grilles at reception.
  • Ensure staff are aware of systems for sharing information with the out-of-hours provider.
  • Ensure staff have an awareness of the Mental Capacity Act (2005) and how it applies to their role.
  • Maintain robust systems for checking and recording checks of emergency equipment to provide assurance that they have been done and the equipment is fit for use.
  • Develop systems for maintaining staff training records so that the practice can be assured that training relevant to staff roles have been completed and any identified development needs met.
  • Ensure policies and procedures are understood by staff and embedded within the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice