Archived: Kingfisher Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kingfisher Practice on 13 July 2016. Overall the practice is rated as Requires Improvement.

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

• The practice had a significant events policy but it was not followed at all times. Staff were unsure what constituted a significant event. Where significant events had been documented, they were investigated appropriately with lessons learnt identified.
• The practice was not aware of the term duty of candour. However, they were following the general principles that ensured when things went wrong patients received reasonable support, an explanation, and a verbal and written apology. They were told about any actions to improve processes to prevent the same thing happening again.
• Practice specific policies were available to all staff but they were not always followed, particularly in relation to the management of significant events, complaints and recruitment.
• Published data showed patient outcomes were low compared to the national average. The practice had employed a nurse to manage patients with long term conditions and they were able to provide evidence that improvements were being made.
• Single cycle audits had been carried out. There had been no completed second cycle audits to show where improvements made were implemented and monitored, although they did have plans in place to complete these.
• The practice did not have a patient participation group.
• Patients said they were treated with compassion, dignity and respect.
• Staff said they felt supported by the management team and had received regular appraisals.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

The areas where the provider must make improvements are:

• Complete infection control audits and review infection control procedures within the practice to identify areas that are not meeting best practice guidance.
• Operate systems and processes effectively to ensure good governance.
• Ensure the significant event policy is followed and staff understand their responsibility to report significant events.
• Implement processes to ensure continuous clinical improvement such as with clinical audit.
• Ensure implementation of a patient participation group to seek and act on feedback from patients.

In addition the provider should:

• Ensure that all staff understand their requirements under the Duty of Candour.
• Ensure the complaints process is followed and all complaints are responded to within the recommended timeframes.
• Implement a system to record stocks of prescribing stationery to include monitoring the distribution of the blank prescription forms.
• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Ensure staff receive the planned update training on safeguarding vulnerable adults.
• Consider having electrical equipment inspected routinely and tested by a competent person.
• Carry out regular fire drills.
• Continue to identify and support carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice