Archived: The Great Sutton Medical Centre - Red

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Great Sutton Medical Centre – Red on 2nd March 2016.

Overall the practice is rated as requires improvement.

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

• There were systems in place to protect patients from risks to their safety, for example, the systems around ensuring sufficient staffing and the management of medication. However we identified improvements that needed to be made to ensure the practice was operating safely.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. The practice worked with other social and healthcare professionals to meet the needs of patients.

• Staff felt supported. They had received an annual appraisal and said they had access to the training they needed. The system for identifying the training needs of staff and ensuring that all staff undertook the training they required for their roles needed revision.

• Patients we spoke with and who returned comment cards were very positive about the care they received from the practice. They commented that they were treated with respect and dignity and that staff were caring, supportive and helpful.

• Services were planned and delivered to take into account the needs of different patient groups.

• Access to the service was monitored to ensure it met the needs of patients. The National GP Patient Survey January 2016 (data collected from January-March 2015 and July-September 2015) showed dissatisfaction with access, for example around getting through to the practice by telephone and access to appointments. Changes had been made to address these issues. Patients spoken with said that they were generally able to get an appointment when one was needed, in particular for urgent issues and that they were happy with the opening hours. Some responses from comment cards indicated continuing issues with access.

• There were systems in place to monitor and improve quality and identify risk. However improvements were needed. A record was not made of all staff meetings. Some policies and procedures needed revision. The work being undertaken to ensure all patients received the health checks they needed at the recommended frequencies needed to continue to demonstrate an improvement to patient outcomes.

• The practice sought feedback from staff and patients, which it acted on. There was an active patient participation group.

• The practice was aware of future challenges and had identified possible service improvements.

There were areas of practice where the provider must make improvements are:

• Ensure that there are systems in place for the management of significant events and that all staff are aware of the reporting process. Ensure there are clear processes for disseminating learning and actions following a significant event investigation and a clear system for review to ensure that actions identified have been and continue to be carried out.

• Ensure that there is a record of the required recruitment information to confirm the suitability of staff employed.

• Ensure there is an effective system for identifying the training needs of staff and ensuring that all staff undertake the training they require for their roles.

• Ensure there is a system in place to update all policies and procedures in line with current guidance and provide clear guidance to staff.

The areas where the provider should make improvements are:

• Ensure the system put in place for the safe management of prescriptions is maintained and all staff are aware of it.

• Carry out a review of the most recent infection control audit to identify that actions taken have been effective and to assess which actions remain outstanding. A timescale for addressing outstanding actions needs to be identified.

• Put a system in place to ensure all health and safety checks are carried out at the recommended frequencies.

• A planned schedule of audits should be put in place.

• Nationally published data showed patient outcomes were lower for some long term conditions when compared to local and national averages. The systems for monitoring that patients were receiving the health care checks they needed at the recommended frequencies needs to continue to ensure that there is an improvement to patient outcomes.

• The system in place for monitoring verbal complaints should be reviewed.

• Review the arrangements for recording staff meetings and to the regularity of meetings amongst the administrative staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice