6 June 2017
During a routine inspection
Letter from the Chief Inspector of General Practice
We previously carried out an announced comprehensive inspection of The Stanmore Surgery on 25 May 2016. The practice was judged to be inadequate and placed in special measures. After this inspection the practice wrote to us to say what action they would take to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:
Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe Care and Treatment.
This announced comprehensive inspection was carried out on the 6 June 2017 to check that action had been taken by the practice to make the improvements required from the inspection in May 2016.
Overall the practice is rated as inadequate from this inspection as it has failed to address a number of issues identified in the previous inspection and further issues were identified.
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Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses. However we found that some incidents that had occurred had not been recorded and investigated as significant events.
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Where an incident had been recorded the practice had not carried out an analysis of the event and recorded learning points that had been identified to show that the practice was fostering a culture of learning and improvement.
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Risks to patients were not assessed and managed.
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Outcomes for patients who use services were not improving, for example latest unpublished QOF data showed the practice was currently achieving only 56% of the overall points available to them.
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Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.
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We were not assured that there was discussion and leadership around best practice and clinical guidelines at practice level.
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Patients who completed comment cards said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
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The practice did not have information on display that informed patients about language interpretation services available.
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The practice had a number of policies and procedures to govern activity, but these were not being followed.
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Though the practice had a leadership structure, there was insufficient leadership capacity and limited formal governance arrangements.
The areas where the provider must make improvement are;
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Ensure care and treatment is provided in a safe way to patients.
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Ensure appropriate standards of hygiene for premises and equipment.
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Ensure effective systems and processes to ensure good governance in accordance with the fundamental standards of care
In addition the provider should:
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Develop a system that obtains patients views on improving the service and review areas where the practice have scored below average from the national GP survey results.
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Provide information or notices advising that formal translation services are available for patients who did not have English as a first language who require translation services.
This service was placed in special measures in May 2016. Insufficient improvements have been made such that there remains a rating of inadequate for safe, effective and well led Therefore we are taking action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice