Archived: The New Parkfield Surgery

Letter from the Chief Inspector of General Practice

Our previous comprehensive inspection carried out in December 2015 found breaches of legal requirements (regulations) relating to the safe, effective and well led domains; and all population groups were rated as requires improvement as a result. The overall rating from the December 2015 inspection was requires improvement and the practice were asked to provide us with a plan of actions they would take to make the required improvements

We carried out an announced inspection on 22 November 2016 to see whether actions taken by the practice had resulted in improvements to the areas we had identified to them.

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

• Improvements had been made to the assessment of risks relating to the health and safety of patients with regards to appropriate fire drills and assessment.
• Improvements had been made to managing significant events. These were now identified and recorded by all staff and regular meetings held to discuss and share learning.
• Improvements had been made in the management of safety alerts. These were being disseminated to relevant staff, acted upon and recorded.
• Some improvements had been made to the governance structure, for example, there was evidence of structured meetings taking place. However, these were not always consistently carried out, and in particular, where a member of staff was absent for six months, the palliative care meeting did not go ahead during this time.
• The practice did not have contingencies in place to follow through with important communications with attached staff when absences occurred. For example; when a health visitor did not attend a safeguarding meeting, the practice did not seek to share the safeguarding concerns with an alternative member of the health visiting team.
• We found that patients were still at risk of harm because effective systems were not fully in place to ensure risks relating to medicines management were sufficiently mitigated and their management was embedded.
• Some patients were at risk of not receiving effective care or treatment. For example, blood testing prior to re issue of a prescription as per protocol.
• Information was not always acted upon in a timely manner to ensure coordinated care and treatment for patients. For example; safeguarding concerns were not kept up to date in some patients records.
• The delivery of high-quality care was not assured by the leadership, governance or culture in place. For example, some systems and protocols were not consistently adhered to

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

· Maintain up to date safeguarding records for all children on their register and ensure that alerts are visible to relevant staff according to their policy.

· Ensure that protocols relating to monitoring of patients on high risk medicines are consistently adhered to.

· Provide effective governance of meetings and communications internally and externally to ensure that vulnerable people are protected through effective communications with relevant teams or agencies.

· Ensure that protocols for shared care agreements are followed.

This was a focussed inspection undertaken to assess the safety and leadership at the practice. Due to concerns found around safeguarding service users and also provision of safe care and treatment, enforcement action has been taken and is detailed at the end of this report. We will return to the practice to ensure that these warning notices have been complied with. If ongoing concerns are found, we will take further action which could include suspension or cancellation of the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice