Archived: Ambar Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Ambar Medical Centre on 4 November 2015. Overall the practice is rated as inadequate.

The provider of Ambar Medical Centre is no longer registered with CQC having retired from the practice in December 2015.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment.
• The practice did not routinely identify, record and analyse significant events in order to identify areas of learning and improvement and so mitigate the risk of further occurrence.
• Arrangements were in place to safeguard children and vulnerable adults from abuse, and local requirements and policies were accessible to all staff.
• Patient outcomes were difficult to identify as there were no systems in place to provide accurate performance data.
• Most patients we spoke with on the day were positive about their interactions with staff and said they were treated with compassion and dignity.
• The practice had limited formal governance arrangements to manage and assess the risk and quality of the service it provided.
• Electronic patient records were not always complete and available in a timely manner.
• It was not always evident from patient records that reviews to medication had taken place or risks considered.

If the provider had still been registered with CQC we would set out the following requirements.

The provider must:

• Ensure appropriate assessments of the risks to the health and safety of patients receiving the care or treatment and doing all that is reasonably practicable to mitigate any such risks.
• Ensure that the practice have robust recruitment arrangements so they are assured that staff providing care or treatment to patients have the qualifications, competence, skills and experience to do so safely.
• The practice must risk assess the need to undertake Disclosure and Barring Service (DBS).
• The practice must develop a system to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients, for example the use of audits, patient feedback and the management of and learning from significant events.
• The practice must maintain an accurate, complete and contemporaneous record in respect of each patient, including a record of the care and treatment provided and of decisions taken in relation to the care and treatment provided.
• The practice must comply with relevant Patient Safety Alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS).
• The practice must implement relevant nationally recognised guidance, including guidelines issued by NICE (National Institute for Health and Care Excellence).

The areas where the provider should make improvement are:

• Consider the benefits to patients and the practice for having registers of patients who may require additional support and care for example patients with learning disabilities and carers.
• The practice should consider the benefits to reviewing the results from patient surveys and developing an action plan to address areas for improvement.
• In the absence of regular team meetings both clinical and non-clinical the practice should consider how they ensure all staff members are kept updated and informed with information relevant to their role.
• In the absence of an Equality impact assessment of the building the practice should consider how they can assure themselves that the all reasonable facilities are available for patients with disabilities.
• Maximise the functionality of the computer system in order that the practice can run clinical searches, provide assurance around patient recall systems, consistently code patient groups and produce accurate performance data.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice