28 September 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at The Practice Drayton Road on 28 September 2016. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
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Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
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There was an open and transparent approach to safety and a system in place for reporting and recording significant events. We saw the practice had acted on significant events. However, the practice had not shared outcomes with all staff or carried out an annual analysis of incidents or in depth to identify any common trends, maximise learning and help mitigate further errors.
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Most patients said they found it easy to make an appointment with urgent appointments available on the same day.
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Patients’ needs were assessed and care was planned and delivered in line with current evidence based guidance.
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Information about how to complain was available but not readily accessible. The practice responded quickly to issues raised.
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The practice had good facilities and was equipped to treat patients and meet their needs.
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There was a staffing structure in place and staff were aware of their own roles and responsibilities.
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An advanced nurse practitioner had been recruited to mitigate the challenges in recruiting a permanent GP and improve access of appointments. Data showed that some patient clinical outcomes were below local and national averages.
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The practice proactively sought feedback from staff and patients, which it acted on.
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The practice had a patient participation group and had implemented suggestions for improvements and had made changes to the way it delivered services as a consequence of feedback.
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Staff held quarterly meetings with healthcare professionals involved in the care of the patients.
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The provider was aware of and complied with the requirements of the duty of candour.
The areas where the provider must make improvement are:
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Carry out a regular analysis of significant events to identify any common trends, maximise learning and help mitigate further errors.
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Implement an effective system that details the actions taken in response to alerts issued by external agencies, for example from the Medicines and Healthcare products Regulatory Agency (MHRA).
The provider should:
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Implement an effective programme of continuous a clinical audit.
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Ensure the practice complaints procedure is accessible to patients.
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Ensure all staff are made aware of the safeguarding lead and are made aware of the contact details for the local safeguarding teams for children and adults.
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Carry out an annual review of complaints to identify any common themes and trends.
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Consider expanding the practice emergency medicines to include anti-histamine medicine or carry out a risk assessment as to why this is not required.
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Explore lower the average satisfaction levels in the national GP patient survey and consider ways to improve people’s experiences of the service received.
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Ensure all staff are made aware of vulnerable patients on the computer system and the clinical code used to identify them.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice