Letter from the Chief Inspector of General Practice
We previously carried out an announced comprehensive inspection of this practice on 12 November 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to Regulations:
- Regulation 15 HSCA (Regulated Activities) Regulations 2014 Safety and suitability of premises.
- Regulation 17 HSCA (Regulated Activities) Regulations 2014 Good governance.
We undertook this focused inspection on the 28 June 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements and issues identified in the previous report. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ellergreen Medical Centre on our website at www.cqc.org.uk.
Overall the practice is rated as good.
Our key findings were:
The practice had addressed the breaches of regulations and other issues identified during the previous inspection and made many improvements including:
- New systems to ensure they were meeting Health and Safety legislation to ensure the safety of both patients and staff. Risk assessments for health and safety had been carried out and action had been taken against the risks identified such as gas, electrical and fire safety.
- New systems to follow national guidelines for the cleaning of premises. There was monitoring of cleaning for the premises and clinical equipment and cleaning equipment had been renewed.
- There was now a formalised practice plan and all staff were involved in discussions about policies and protocols at protected learning events.
- The training matrix had been renewed and kept updated on a monthly basis which made it clear when staff training was due. All staff had received training relevant to their role and additional training had been attended for example, computer training.
- The practice had employed a pharmacist who was helping the practice address the high level of hypnotic medication prescribing. The practice had managed to reduce antibiotic prescribing rates by 6.8%. The practice had introduced monitoring systems for uncollected prescriptions.
- The practice had employed an information facilitator who had renewed the recall system and who liaised with the local mental health team to help ensure annual physical health checks for all patients experiencing poor mental health were completed and correctly recorded.
- The practice was carrying out a rolling programme of GP and nurses’ consultation audits to ensure all clinicians are following appropriate guidance in relation to treatment and medical record keeping.
- The practice had sought other ways of gaining patient feedback and had also conducted a staff survey.
- The practice had considered further ways to improve patient satisfaction with regards to making appointments and looked at tackling the high patient fail to attend rate for appointments.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice