The Wycliffe Medical Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 15 March 2016. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulations 12 and 19.

We undertook a focussed inspection on 3 November 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements. You can read the last comprehensive inspection report from March 2016 by selecting the ‘all reports’ link for The Wycliffe Medical Practice on our website at www.cqc.co.uk

Overall the practice is rated as Good. Safe remains as requires improvement and well-led has improved from requires improvement to good. The overall rating for all the population groups is good.

• We found that a new significant event system had been put in place. The policy and reporting form had been updated. Some further improvement was required to ensure that the investigations were detailed and actions were identified and implemented and meetings minutes represented the discussion that took place.

• The practice had implemented an effective system for dealing with patient safety alerts.

• Risks to patients were now assessed and well managed. For example, administration staff carrying out urine testing, printer prescription stationery, blue prescription pads used for substance misuse.

• Action had been taken to address identified concerns with infection prevention and control practice.

• Two further fire drills had taken place since the last inspection and actions had been identified and completed.

• Monitoring of staff training now took place.

• Recruitment arrangements for staff were now in line with national guidance.

• A new complaints system had been put in place.

• The practice now had an effective governance system in place.

• The practice had commenced a more formalised process for the recording of minutes of meetings but the minutes still required more detail.

The areas where the provider must make improvements are:

• Continue to embed the new system for significant events to ensure investigations are detailed, actions are identified and implemented and meetings minutes represent the discussion that takes place.

The areas the provider should make improvements are:

• Continue to embed the process for the documentation of risks on the new practice risk register.

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 at The Wycliffe Medical Practice on 15 March 2016.  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. However, reviews and investigations were not thorough enough.
• The practice did not have a robust system in place to manage and monitor risks to patients, staff and visitors to the practice.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

• Have a system in place to ensure significant events and complaints are investigated fully, identified actions implemented and any learning cascaded to staff.

• Implement a robust system for dealing with safety alerts.

• Ensure there is an effective governance system in place to identify and mitigate risks to patients and staff in relation to the completion of actions for administration staff carrying out urine testing, printer prescription stationary, blue prescription pads used for substance misuse.

• Ensure recruitment arrangements include all necessary employment checks for all staff and are in line with Section 3 of the Health and Social Care Act 2008. 

• Embed a process to ensure staff training is monitored and all staff are up to date with mandatory training.

In addition the provider should:

• Ensure an action plan from the fire drill in November 2015 is put in place with persons responsible and timeframe for completion of actions.
• Embed a consistent and formal system for dissemination of NICE clinical guidance to all staff.  
• Put a system in place to monitor QOF in relation to exception reporting to ensure actions are taken where required.
• Improve the coding for vulnerable adults on the patient record system.
• Have in place a schedule of minuted meetings.

Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice