Archived: Burton Road Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Burton Road Surgery on 18 December 2015. Overall the practice is rated as requires improvement.

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

• There was an open and transparent system in place for reporting and recording significant events. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had 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.

• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.

• The provider was aware of and complied with the requirements of the Duty of Candour.

• Risks to patients were assessed and well managed, with the exception of those relating to Disclosure and Barring Service checks (DBS check). (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

• The provider was unable to provide evidence that staff acting as a chaperone had received the relevant training and there was no evidence that chaperones had a DBS check in place.

• Data showed patient outcomes were low compared to the locality and nationally.

• Although some clinical audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.

• The practice had proactively sought feedback from patients and had an active patient participation group.

The areas where the provider must make improvements are:

• Ensure all clinical staff and those who have contact with vulnerable adults and children have a DBS check in place.

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

• Ensure chaperones have a DBS check in place or a policy or risk assessment in place to define the requirements for chaperones to have a DBS check.

• Carry out clinical audits and re-audits to improve patient outcomes.

In addition the provider should:

• Ensure all clinical staff are aware of the location of emergency drugs and the contents of the emergency drugs bag.
• Carry out a disability access audit to assess disabled access for patients and identify reasonable adjustment measures to be taken.
• Ensure appropriate records and evidence of staff training are held by the practice.
• Ensure the infection control lead receives an appropriate level of infection control training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice