18 April 2017
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Park Avenue Medical Centre on 4 July 2016. The overall rating for the practice was requires improvement due to breaches of legal requirements. After the comprehensive inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to:
- Regulation 12 (RA) Regulations 2014, safe care and treatment.
- Regulation 17 HSCA (RA) Regulations 2014, good governance.
The full comprehensive report of the inspection on 4 July 2016 can be found by selecting the ‘all reports’ link for Park Avenue Medical Centre on our website at www.cqc.org.uk .
This inspection was a focused follow up inspection carried out on 18 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 4 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is now rated as ‘Good’.
From the inspection on 4 July 2016, the practice was told they must:
- Ensure arrangements were in place for identifying, assessing and mitigating risk in relation to non-clinical staff undertaking chaperone duties. This included risk assessment of whether DBS checks were required.
- Implement a system to ensure patients prescribed with high risk medicines were monitored appropriately.
- Ensure a Legionella risk assessment was undertaken and arrangements were in place to identify, assess and manage all risks associated with the premises.
We also told the practice that they should make improvements to the follows areas:
- Review how significant events and incidents were identified, documented and learning was shared.
- Continue to monitor Quality and Outcomes Framework (QOF) exception reporting to ensure clinical effectiveness.
- Review the arrangements for making contact with bereaved families to offer appropriate support.
Our key findings were as follows:
- Systems were in place for identifying, assessing and mitigating risk in relation to non-clinical staff undertaking chaperone duties. Non clinical staff that undertook chaperone duties had been checked through the Disclosure and Barring Service (DBS) and trained for this role.
- The practice had made the necessary changes to their procedures for managing high risk medicines. Patients prescribed with high risk medicines were now monitored appropriately.
- The practice confirmed that following a Legionella risk assessment by an external agency arrangements were in place to manage the risks associated with the premises.
- The arrangements for reporting significant events and incidents had been strengthened with specific improvements made to the system for identification documentation and sharing of learning points.
- A protocol was in place to monitor and manage the exception reporting process in relation to the Quality and Outcomes Framework (QOF).
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A protocol was in place to ensure contact with bereaved families to offer appropriate support.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice