Archived: Henley Green Medical Centre

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection of Henley Green Medical Centre on 10 January 2017. The practice was rated as requires improvement overall, with safe rated as inadequate. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Henley Green Medical Centre on our website at www.cqc.org.uk.

This inspection was a follow up comprehensive inspection carried out on 26 September 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 10 January 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is now rated as Good.

Our key findings were as follows:

• The practice had carried out necessary training to enable staff to carry out the duties they are employed to perform safely and effectively.

• Appropriate pre-employment checks were completed for all staff employed by the practice in line with their recruitment policy.

• Risks to the health and safety of staff and service users receiving care and treatment were assessed and effectively managed.

• Staff who acted as a chaperone had received a Disclosure and Barring Service (DBS) check and appropriate training.

• The practice had an effective programme of quality improvement activity including clinical audit.

• There was an effective system in place to enable the practice to ensure that appropriate action had been taken in relation to patient safety alerts.

• Staff had been briefed on the existence of the practice business continuity plan, business continuity arrangements and their responsibilities in relation to this.

• The practice had reviewed the decision that GPs do not carry a range of emergency medicines for use in acute situations when on home visits and had undertaken a risk assessment in relation to this. The practice will review this every three months.

• Staff had received Hepatitis B immunisation boosters.

• The practice had continued to improve the arrangements in place to monitor patients being prescribed high risk medicines and had changed the re-authorisation of these from every six months to every three months.

• The practice had encouraged patients to engage with national cancer screening programmes, especially in relation to screening for breast cancer and had signed up to take part in a Coventry-wide initiative due to take place in 2017.

• An additional GP partner had been appointed and this had enabled lead roles and governance to become more clearly defined.

• The practice had joined the local GP federation, a group of practices who worked together to improve healthcare with the locality.

However there was an area of practice where the provider should make improvements:

• The practice should continue to closely monitor data for the cervical screening programme and identify ways to increase patient take up when possible.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Henley Green Medical Centre on 10 January 2017. Overall the practice is rated as requires improvement.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
• Risks to staff and patients were not always assessed and well managed. Staff had not received a full range of appropriate training and there was no evidence of health and safety or fire risk assessments. The practice did not carry out fire evacuation drills.
• The practice carried out clinical audit activity. However, none of the audits we saw demonstrated improvements to patient care as a result of the audit.
• The practice had not followed their own recruitment policy when appointing staff. Staff members had been appointed without proof of experience or references being sought.
• Feedback from patients about their care was positive compared to local and national averages. Patients reported that they were treated with compassion, dignity and respect.
• Patients were able to access same day appointments. Pre-bookable appointments were available within acceptable timescales. Feedback from patients about access to services was consistently higher than local and national averages.
• The practice had a number of policies and procedures to govern activity, which were easily accessible to staff.
• The practice sought feedback from patients and implemented suggestions for improvement and made changes to the way they delivered services in response to feedback.
• The practice used the Quality and Outcomes Framework (QOF) as one method of monitoring effectiveness and had achieved an overall result which was lower than local and national averages. Practice clinicians were unable to explain some high clinical exception rates.
• Information about services and how to complain was available and easy to understand.

However, there were areas where the provider must make improvements. Importantly, the provider must:

• Ensure staff employed by the provider receive such training as is necessary to enable them to carry out the duties they are employed to perform safely and effectively.
• Ensure appropriate pre-employment checks are completed for all staff employed by the practice in line with their recruitment policy
• Ensure risks to the health and safety of staff and service users receiving care and treatment are assessed and effectively managed.
• Ensure all staff who act as a chaperone undertake a disclosure and barring service (DBS) check and apprirate training.
• Develop a more effective programme of quality improvement activity including clinical audit.
• Put an effective system in place to enable the practice to satisfy themselves that appropriate action has been taken in relation to patient safety alerts.

The practice should also:

• Educate staff on the existence of the practice business continuity plan, business continuity arrangements and their responsibilities in relation to this.
• Review the decision that GPs do not carry a range of emergency medicines for use in acute situations when on home visits. Keep a written record of what the review considered and the outcome.
• Make arrangements for relevant staff to receive Hepatitis B immunisation boosters.
• Continue to improve the arrangements in place to monitor patients prescribed high risk medicines.
• Encourage patients to engage with national cancer screening programmes, especially in relation to screening for breast cancer.

Where, as in this instance, a provider is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected no longer than six months after the initial rating is confirmed. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice