Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Hazeldene Medical Centre on 3 February 2017. Overall the practice is now rated as good.
The practice had been previously inspected on 21st October 2015. Following this inspection the practice was rated requires improvement with the following domain ratings:
Safe – Requires improvement
Effective – Requires improvement
Caring – Good
Responsive – Good
Well-led – Requires improvement
Our key findings from the most recent inspection were as follows:
- There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events with learning outcomes documented.
- Staff had a clear understanding of their roles and responsibilities in line with their job description.
- Infection control processes had been introduced with several audits having taken place with actioned outcomes documented and evidenced.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
- The practice had developed a programme of continuous quality improvement through clinical and internal audits, and these were used to monitor quality and to make improvements.
- Risks to patients were assessed and well managed.
- There was a clear leadership structure. The practice proactively sought feedback from staff and patients, which it acted on. The practice had an active patient participation group (PPG).
- Patients said they found it difficult to access the practice by the phone. Most patients found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
- The provider was aware of and complied with the requirements of the duty of candour.
The areas where the provider should make improvements are:
- Continue to review the telephone and appointment system action plan, to enhance patient experience of access to appointments.
- Use practice data more effectively to monitor performance in areas of exception reporting.
- Ensure care plan templates themselves are updated.
- Review processes in relation to the repeat prescribing policy, whilst implementing a serial checking process for blank prescriptions.
- Add the full address of the Parliamentary and Health Service Ombudsman(PHSO) to the practice leaflet.
- Install an alert system on the practice entrance, so staff can help wheelchair users to access the building.
- Proactively identify carers.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice