Archived: Deer Park

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Deer Park on 27 September 2016. Overall the practice is rated as good. However, improvements were required in providing effective services. Our key findings were as follows:

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

• The practice’s patients and staff had recently been informed that the practice was closing in March 2017. The patient list was to be dispersed among the local population.
• There was a system in place for reporting and recording significant events and for learning to be circulated to staff and changes implemented where required. Reviews of complaints, incidents and other learning events were thorough.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ ongoing needs and when they delivered care to patients it was in line with current evidence based guidance.
• The practice was performing well on most clinical outcomes in terms of national data. However, national data suggested patients did not always access reviews of their conditions or meet standards of managing their care in line with national guidance as in some clinical areas there were significantly higher instances of patients not being included in national data outcomes.
• Reviews of patients on repeat medicines were not always recorded properly to ensure this system was monitored properly and this had not been identified as an area for improvement or further monitoring.
• The practice planned its services based on the needs and demographic of its patient population.
• There were well developed processes to ensure the continuity of care, particularly for patients with the most complex health needs.
• Staff were trained in order to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patient feedback in the CQC comment cards suggested patients felt staff were caring, committed and considerate.
• 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.
• There was an ethos of continuous learning and improvement.

Areas the provider must make improvements are:

• Identify, mitigate and improve the monitoring of patient care to ensure patients receive effective care and treatment. Specifically improve the recording and monitoring of medicine reviews and identify means of improving take up of health checks for patients with long term conditions.

Areas the provider should make improvements are:

• Ensure that where tasks are required and identified (such as those identified through risk assessments) that these are completed. Specifically, ensure that water temperatures are tested in line with the legionella assessment and that deep cleaning required in the infection control audit is undertaken.
• Review and assess the provision of Hepatitis B immunisation to reception staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice