Archived: Metheringham Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Metheringham Surgery on 15 December 2015. Overall the practice is rated as requires improvement.

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. Incidents and near misses were discussed in monthly practice meetings.

• Risks to patients were assessed and well managed, the provider had a risk register in place to identify risk and an action plan to address risks identified.

• Information about services and how to complain was available and easy to understand.

• The practice encouraged patient feedback using different methods to ensure the practice provided high quality services for patients and planned to make improvements for the benefit of its patients. The practice did not have an active patient participation group (PPG).

• Data showed patient outcomes were low compared to the locality and nationally. As the provider had taken over the contract for this practice on 1 April 2015, a key objective was to improve patient outcomes and improve the quality and provision of services for patients.

• Results from the national GP patient survey showed patients responded negatively to questions about their involvement in planning and making decisions about their care and treatment. Results were below local and national averages.

• Patient Group Directions (PGDs) had been adopted by the practice to allow nurses to administer medicines in line with legislation. A practice nurse was responsible for the coordination of all PGDs.

• Not all staff acting as a chaperone had completed the relevant training to fulfil the role.

• Urgent appointments were usually available on the day they were requested.

• The practice had a number of policies and procedures in place to govern activity.

The areas where the provider must make improvements are:

• Ensure all staff who act as a chaperone are competent to fulfil the role.

In addition the provider should:

• Carry out a disability access audit to assess disabled access for patients and identify reasonable adjustment measures to be taken.
• Ensure infection control lead receives an appropriate level of infection control training.
• Ensure members of staff who act as a chaperone receive an appropriate level of training.
• Improve the frequency of multi-disciplinary meetings to discuss patients care and needs.
• Ensure all significant events reported are reviewed in a timely manner, ensuring lessons learned and actions to be taken are recorded following review.
• Ensure appropriate records and evidence of staff training are held by the practice.
• Ensure there is a clinical leadership structure in place within the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice