Archived: Drayton Road Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Drayton Road Surgery on 1 December 2015. 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. Learning and outcomes were not always shared to reduce the risk of reoccurrence.
• Risks to patients were assessed but were not always actioned, such as those relating to safety alerts, legionella and infection control.
• Data showed patient outcomes were good for the locality. Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
• Patients said they were treated with compassion, dignity and respect and were cared for.

• Information about services was available but information on how to complain was not clearly signposted.

• Urgent appointments were usually available on the day they were requested.
• The practice had a number of policies and procedures to govern activity which were regularly reviewed, with the exception of some Patient Group Directions.
• The practice had proactively sought feedback from patients and had an active patient participation group.

The areas where the provider must make improvements are:

• Investigate significant events and complaints thoroughly and ensure that required action is taken and outcomes and learning are shared to reduce the risk of reoccurrence.

• Ensure medicines are managed appropriately and that a cold chain policy is developed and followed with regard to the storage of vaccines.

• Ensure that patients’ medication is kept under review to minimise risks associated with taking medicines that require monitoring.

• Review all emergency equipment and medicines to ensure they remain ready for use in a medical emergency.

• Improve staff knowledge and understanding of responsibilities regarding appropriate safeguarding of vulnerable adults.

• Take action to mitigate the risks identified in legionella and infection control audits.

• Develop an effective system for allocating roles and responsibilities to ensure identified risks are monitored.
• Take account of the risks associated with the future sustainability of the practice, giving adequate provision to succession planning in light of proposed staff changes and the increased demand on the service.

In addition the provider should:

• Improve procedures for updating Patient Group Directions.

• Provide patients with clear information on how to complain.

• Implement a system for responding to uncollected prescriptions on patients’ records.
• Encourage a more systematic approach to registering carers.
• Develop more formalised processes for multi-disciplinary meetings and discussions to improve outcomes for vulnerable and high risk patients.
• Complete full cycle audits to evaluate and improve the quality of services provided.

Where a practice is rated as inadequate for one of the five key questions or one of the six population groups the practice will be re-inspected within six months after the report is published. If, after re-inspection, the practice has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place the practice into special measures. Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice