Archived: The Birches Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Birches Medical Centre on 11 April 2016. The overall rating for the practice was good. The full comprehensive report on the 11 April 2017 inspection can be found by selecting the ‘all reports’ link for The Birches Medical Centre on our website at www.cqc.org.uk.

At our previous inspection on 11 April 2016, we rated the practice as requires improvement for providing safe services as the arrangements in place for managing the following issues were not adequate:

• staff did not work within the scope of their practice and flu vaccinations were given without the authority of a GP.

In addition we identified the following issues the service should improve:

• A record should be kept of the investigation and review of all significant events.

• A system of continuous clinical audit should be established to test the effectiveness of the service and to monitor quality and make improvements.

• A record should be kept of meetings held for the purpose of monitoring issues discussed.

• The temperature of the vaccine fridges should be checked daily and medicine stock levels should be audited.

• A record should be kept of the work carried out to improve infection control so that it can be monitored, and a review date logged for the next infection control audit.

In line with agreed timescales the practice supplied documentary evidence to demonstrate how they had improved their practices in relation to the overview of safety systems and processes since the last inspection.

This inspection was an announced focussed inspection carried out on 10 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation that we identified in our previous inspection on 11 April 2017.

At this inspection we found that sufficient improvement had been achieved to update the rating for provision of safe services to good. The practice had addressed the breaches of regulation and was now compliant with all regulations. This report covers our findings in relation to those improvements.

Our key findings were as follows:

• New systems were in place for recording and monitoring significant events and clinical audits.

• There was a system for recording staff discussions and meetings.

• Additional staff training had been provided.

• Records for monitoring medicine stock levels were recorded for the purpose of auditing.

• Relevant procedures were altered to support these changes to practice.

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 The Birches Medical Centre on 11 April 2017. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.

• 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.
• Results from the national GP patient survey 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.
• Four of the eight patients spoken to said they sometimes found it difficult to make an appointment with a named GP. This was also reflected in the CQC comment cards we received.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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 the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice