Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 1 March 2016. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:

Fit and proper persons employed

How the regulation was not being met:

Recruitment arrangements did not include all necessary employment checks for all staff.

Regulation 19(3)(a) schedule 3

This inspection was a desk-based review carried out on 19 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 1 March 2016. This report covers our findings in relation only to those requirements.

The full comprehensive report on the Month Year inspection can be found by selecting the ‘all reports’ link for Bartholomew Medical Group on our website at www.cqc.org.uk.

Overall the practice is rated as good.

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 Bartholomew Medical Group on 29 February and 1 March 2016. Overall the practice is rated as good. Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Weekly audits of a system read code ensured smooth passage of referral for patients, as a ‘belt and braces’ approach.

• Systems were in place to assess risks to patients however they were not always followed. Full recruitment checks had not been undertaken for staff prior to employment.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had 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.
• Urgent appointments were usually available on the day they were requested.
• Information about services and how to complain was available and easy to understand.
• The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the Duty of Candour. This means providers must be open and transparent with service users about their care and treatment, including when it goes wrong.

We saw one area of outstanding practice:

The practice regularly used a dementia assessment tool to assess changes in patients at risk of dementia. The strengths of the assessment tool included: short administration and scoring time (8–10 minutes); assessment of multiple cognitive areas sensitive to dementia, high sensitivity in detecting early Alzheimer’s disease, and a large range of scores in the mild impairment range, allowing detection of subtle changes over time. This had reduced onward referral rates to memory clinics by more than 50 per cent.

The area where the provider must make improvements are:

• Ensure recruitment arrangements include all necessary employment checks for all staff.

The area where the provider should make improvements are:

• Ensure the Practice Manager has access to key documents in the absence of the Business Manager.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice