Archived: Victoria Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Victoria Medical Centre on 14 April 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, we found that the practice had not learned from some of their significant events or put plans in place to prevent them happening again.
• Some risks to patients were assessed and well managed. However, for example, there was no health and safety or fire safety risk assessment at the branch surgery. The nursing team had not been subject of DBS checks.
• Data showed patient outcomes were low compared to the national average. We saw that clinical audit was making improvements to patient outcomes.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice had a high number of carers coded on the practice system; this was 174 which was 5.9% of the practice population. The practice offered them health checks and flu immunisations.
• Patients said they were able to get an appointment with a GP when they needed one, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had a system in place for handling complaints and concerns and responded quickly to any complaints. However, the information given to patients on how to complain did not contain the information on the process to follow if the complainant remained unhappy with the outcome.
• There was a leadership structure in place and staff felt supported by management. However, the partners could not demonstrate an active involvement in the governance or day to day running of the practice.
• The provider was aware of and complied with the requirements of the Duty of Candour.
• Feedback from patients was limited. There was no patient participation group and no recent survey of patients on general feedback for the practice.
• The practice had done well to identify carers amongst its patient population. (5.9% of their practice population)

The areas where the practice must make improvements are;

• Ensure systems and processes are established and operated effectively.
• Ensuring learning from significant events is shared and acted upon in order to minimise the risk of events being repeated.
• Ensure that the performance of the practice is understood in relation to QOF to improve patient care.
• Ensure they follow systems and processes in relation to infection control and training and carry out a legionella risk assessment.
• Ensure DBS checks are carried out where appropriate.
• Ensure staff receive appropriate training in order to carry out the duties they perform and maintain accurate records of this.

The areas where the provider should make improvements are:

• Consider updating the recruitment policy to contain full information on recruitment checks.
• Consider how they obtain and act on feedback from patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice