10 February 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Beechcroft Medical Centre on Thursday 10 February 2016. Overall the practice is rated as inadequate.
Our key findings across all the areas we inspected were as follows:
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Procedures for reporting, recording, taking appropriate action and sharing learning from significant event analysis (SEAs) were inadequate.
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Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, those relating to fit and proper persons employed, recruitment checks, staffing, safeguarding, chaperoning, infection control, health and safety, equipment, medicines management, dealing with emergencies and patient referrals.
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Risk assessments were poorly recorded and any risks identified were not actioned.
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There was little evidence that audits were driving improvement.
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The appointment system was not effective. Patients did not receive timely care when they needed it as they were unable to book appointments online and they experienced long waiting times to get through to the surgery by telephone to book routine or emergency appointments.
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The practice failed to make every reasonable effort to recruit a male GP to the practice.
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The practice had limited formal governance arrangements.
The areas where the provider must make improvements are:
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Develop and implement a vision and strategy to improve services for patients and ensure governance processes are in place to monitor safety and risk.
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Introduce processes for reporting, recording, acting on, sharing and monitoring significant events, incidents and near misses and ensure staff are aware of and comply with the requirements of the Duty of Candour in the event of a notifiable safety incident.
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Ensure systems and processes to safeguard adult and children from abuse are established and operated effectively and all staff receive up to date safeguarding training.
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Take action to address identified concerns with infection prevention and control practice and in relation to premises and equipment, maintain standards of hygiene appropriate for the purposes for which they are being used.
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Put systems in place for the secure storage of prescription pads and the monitoring of their use.
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Ensure recruitment arrangements include all necessary employment checks for all staff and undertake a risk assessment on the need for a Disclosure and Barring Service (DBS) check for staff providing a chaperone service. Ensure staff are trained and aware of their responsibilities when acting as a chaperone.
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Ensure annual testing of all electrical equipment and calibration of clinical equipment are carried out and the premises are properly maintained with comprehensive risk assessments carried out in order to identify any shortfalls and take remedial action. For example, in relation to treatment rooms.
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Ensure sufficient numbers of suitably qualified staff are deployed to meet people’s care needs and ensure fit and proper persons are employed in clinical roles.
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Ensure appropriate arrangements are in place for managing medical emergencies including: availability of an automated external defibrillator (AED) or undertake a risk assessment if a decision is made to not have an AED on-site and staff training in basic life support.
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Ensure signed Patient Group Directions (PGDs) allowing the practice nurse to administer medicines in line with legislation are up to date.
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Ensure a comprehensive business continuity plan is in place for major incidents.
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Carry out clinical audits including re-audits to ensure improvements have been achieved.
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Ensure an induction programme is in place that prepares staff for their role and ensure staff participate in mandatory training including information governance and are provided with appropriate policies and guidance to carry out their roles in a safe and effective manner and ensure they receive regular appraisal of their performance.
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Ensure the GP actions all referrals in a timely manner.
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Ensure privacy is maintained at the reception desk and dignity is maintained during examinations, investigations and treatments.
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Ensure all clinical staff understand the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.
The areas where the provider should make improvement are:
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Improve processes for making appointments over the phone and online.
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Ensure they respect people’s preferences in relation to who delivers their care and treatment such as a male GP.
This provider cancelled their registration at the end of October 2016.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice