Archived: Eltham Medical Practice Also known as The Court Yard Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Eltham Medical Practice on 19 May 2016. Overall the practice is rated as requires improvement.

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

• Significant events had been investigated thoroughly and learning from these was shared among clinical staff, but some staff did not have a clear understanding of significant events or the process for reporting them. Some incidents had not been recorded.

• Risks to patients were not always well assessed or well managed. This was in relation to ineffective medicines management systems, the absence of electrical safety checks, mandatory training and some recruitment checks. There was no documentation of fire drills.

• Data showed patient outcomes were in line with the national average.

• There was evidence that audits were driving improvements to patient outcomes.

• The national GP patient survey published in January 2016 showed the practice was rated in line with local and national averages for several aspects of consultations with GPs and nurses.

• The majority of patients we spoke with said they were treated with compassion, dignity and respect. However, several of them had found it difficult to get appointments.

• Information about services and avenues of support was not always available for patients to access. Complaints had not been managed in line with recognised guidance and contractual obligations.

• There was a governance structure in place and all staff felt supported by the practice’s leaders, but not all of the practice’s processes had been managed effectively.

The areas where the provider must make improvements are:

• Ensure recruitment arrangements include all necessary employment checks for all staff, ensure all clinical staff have indemnity insurance in place and maintain records of their professional registration.

• Ensure all mandatory training is completed and documented.

• Ensure the system for managing medicines is effective and that stock is properly controlled.
• Ensure electrical equipment is checked regularly to ensure it is safe to use.

• Ensure its complaints procedures are in line with current legislation, guidance and contractual obligations.

In addition the provider should:

• Ensure all staff have a good understanding of significant events, and implement a significant event protocol.

• Consider providing training for clinical staff on the Mental Capacity Act.

• Ensure outstanding appraisals are completed, and inductions are documented for all new staff.
• Ensure fire drills are documented.
• Continuously monitor feedback from patients to identify and act upon any further areas for improvement, particularly in relation to access to appointments.
• Consider advertising the private room available to patients who wish to have confidential discussions.

• Improve the process for identifying and providing support for carers and arrange interpreters for patients who are unable to speak English.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice