14 September 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at the Family Healthcare Centre on 14 September 2015. This followed an inspection in October 2014 that placed the practice into special measures due to its rating of inadequate. The outcome of this inspection has identified that the practice is now rated as requires improvement.
Specifically, we found the practice to require improvement for providing safe, effective, responsive and well led services. It also requires improvement for providing services for older people, people with long-term conditions, families children and young people, working age people (including those recently retired) and people experiencing poor mental health (including people with dementia). It was good for providing a caring service to patients.
Our key findings across all the areas we inspected were as follows:
- Most areas of risk associated with the safe running of the service were managed safely although some areas still required improvement such as legionella management and complaints.
- Patients said they were treated with dignity, kindness and respect and they were involved in their care and decisions about their treatment.
- Patients told us they sometimes had difficulty arranging an appointment although urgent appointments were usually available on the day they were requested.
- The practice was visibly clean and they had improved systems to ensure that safe infection prevention and control procedures were being followed.
- Staff told us that communication within the practice had improved and they valued being part of a team.
Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.
However, there were also areas of practice where the provider needs to make improvements.
Importantly, the provider must:
- Ensure that systems are in place to manage and monitor risks to the quality and safety of the service in relation to legionella management and risks to the continuity of the service.
- Ensure that the incident reporting procedure is followed by staff at all times.
- Non -clinical staff who act as a chaperone must receive appropriate training and a risk assessment so that an appropriate level of criminal records check is completed before they undertake the role
- Ensure that patient information received from specialist services are accurately recorded in the electronic records so that medicines are safely and accurately prescribed.
- Ensure that records are maintained to demonstrate that appropriate staff are employed by the practice.
- Improve the complaints process so that all complaints are managed in a timely way and in accordance with the policy so that learning is shared and actioned.
In addition the provider should:
- Make information available to patients about chaperones on the practice’s website.
- Include guidelines in the recruitment policy on which staff roles require a check with the Disclosure and Barring Service.
- Develop care plans for all patients at high risk of unplanned admissions to hospital.
- Ensure audits of the completeness of clinical records are in place
On the basis of the ratings given to this practice at this inspection, we are removing this provider from special measures. We will inspect the practice again to ensure that it continues to make improvements.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice