Archived: Surrey Docks Health Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Surrey Docks Health Centre on 18 August 2016. 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 an effective system in place for reporting and recording significant events and most significant events reviewed showed clear analysis and action points. However some staff were unaware of how to access the significant event reporting form and learning from actions was not always documented.
• Most risks to patients were assessed and well managed though the practice had yet to address some of the actions outlined in their fire risk assessment and records of staff immunity to common communicable diseases were incomplete.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. However the practice did not have valid PGDs in place to enable the practice nurse to administer medicines. Patients were not proactively followed up after unplanned secondary care attendances.
• Staff had been trained to provide them with 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. Improvements were made to the quality of care as a result of complaints and concerns.
• Most patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day, though some patients said that waiting times were lengthy and telephone access to book an appointment was poor.
• 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 patients and allowed staff to voice concerns and suggestions, which it would act on.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Work to improve processes around the management of medicines including systems for securing prescriptions and ensure that nursing staff are always administering medicines in line with valid patient group directions.

• Ensure that processes are in place to mitigate against risks associated with fire and the spread of common communicable diseases.

The areas where the provider should make improvement are:

• Continue to review the practice’s telephone access and appointment times with a view to improving patient access and reduce waiting times and continue to host regular Patient Participation Group (PPG) meetings.

• Assess effectiveness of current system for reviewing test results to ensure that all results are actioned in a timely manner.

• Ensure that all staff are clear around the process for assessing capacity and consent of minors and the process for reporting and managing significant events.

• Ensure that all emergency equipment is within its expiry date and fit for use.

• Ensure that all staff complete training appropriate to their roles regularly.

• Continue to undertake comprehensive recruitment checks for all members of staff and undertake annual appraisals for salaried GPs and continue to document the induction process of all new staff members.

• Continue with the planned work to increase the identification of carers and support provided to them.

• Ensure that the practice complaints procedure is in line with legislation and guidance.

• Put systems in place to ensure that vulnerable patients are proactively followed up after unplanned admissions to secondary care.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice