Brook Lane Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Brook Lane Surgery on 15 December 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the December 2016 inspection can be found by selecting the ‘all reports’ link for Brook Lane Surgery on our website at www.cqc.org.uk.

This inspection was a further announced comprehensive inspection on 5 September 2017. Overall the practice is now rated as good.

Our key findings were as follows:

• The practice had improved systems and processes for reporting significant events.

• The practice had reduced the risk to prescription stationery security during periods when clinical and treatment rooms were not in use.

• The practice had completed actions identified in their health and safety risk assessments.

• The practice had arrangements in place to respond to emergencies and major incidents.

• The practice worked with the patient participation group to conduct surveys and make improvements to the practice.

• The practice had reviewed their governance strategy and created two assistant practice manager posts.

• The practice stock of emergency medicines was not complete as the practice were awaiting delivery of stock. This had been received within two days of this inspection.

• One patient group direction (PGD) for use with vaccines had been signed by staff on 4 September 2017 despite it going out of date in April 2017.

There were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure care and treatment is provided in a safe way to patients.

In addition the provider should:

• Continue to review ways to improve identification of patients registered at the practice who are also carers.

• Continue to review patient feedback regarding access to appointments.

• Continue to review ways to monitor the performance of non-clinical staff.

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 Brook Lane Surgery on 15 December 2016. Overall the practice is rated as requires improvement.

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

• Risks to patients were assessed and managed, but there were shortfalls in implementing changes needed.
• The majority of patients said they were treated with compassion, dignity and respect. However, not all felt that they could make appointments to see a GP easily.
• The practice had a number of policies and procedures to govern activity, but some were overdue a review according to the document review dates.
• The GP partners had a vision of collaborative working with primary and secondary healthcare.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Ensure that infection prevention audit recommendations are actioned.

• Ensure blank prescription stationery is stored securely and tracked.

• Ensure regular checks are carried out to monitor the temperatures of medicine refrigerators to ensure they are operating within safe limits.

• Ensure the required checks are carried out on staff who are recruited.

• Ensure actions from the health and safety and fire assessments from March 2016 are actioned.

• Ensure there is a business continuity plan in place in the event of a disruption to the service and make sure all staff are aware of the contents and actions to take.

• Ensure staff are given regular appraisals relevant to their role.

• Ensure complaints are actioned appropriately within the practice.

• Ensure all policies and procedures are reviewed and updated when needed to reflect relevant information and best practice. To include for chaperones, complaints and infection control.

The areas where the provider should make improvements are:

• Consider creating a locum pack so that all the relevant information is easily accessible.

• Review arrangements to promote patient involvement in decisions about their care.

• Continue to identify more patients who are carers and provide them with support.

• Review appointment availability to improve the number of bookable appointments and review arrangements to improve telephone access.

• Review patient understanding of the role of nurse practitioner; consider patient awareness (when making a GP appointment) whether the appointment is with a nurse practitioner instead of a GP.

• Review systems in place which enable staff and patients to provide feedback on the service provision.

• Consider reviewing infection control audit to include all areas of the practice building, including reception and waiting room.

• Review the availability of GP appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice