Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Berrymead Medical Centre on 13 September 2016. Overall the practice is rated as requires improvement.

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

• There was an effective system in place for reporting and recording significant events. Safety alerts were received and acted upon.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Staff had been trained to deal with medical emergencies and emergency medicines and equipment were available.
• 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 and easy to understand.
• Feedback from patients indicated they had difficulty getting through to the practice by telephone and sometimes appointments were hard to get.
• The practice sought feedback from staff and patients, which it acted on.

• Staff were supervised, felt involved and worked as a team.

• The provider was aware of and complied with the requirements of the duty of candour.
• Improvements were needed to ensure the safe storage of prescription pads

• Improvements were needed to governance systems and processes to ensure that health and safety risks to patients were assessed, monitored and mitigated.

• Improvements were needed to governance systems and processes to ensure that the quality of services was assessed, monitored and improved.

The areas where the provider must improve are:

• The provider must ensure that all prescription pads are stored securely.

• The provider must ensure that health and safety policies and procedures are implemented and are regularly reviewed and updated according to legislation and national guidance. Ensure that electrical installation safety tests and fire safety drills are carried out.

• The provider must ensure that risks are assessed, monitored and mitigated including health and safety, environmental, fire, lone working, management of unforeseen circumstances (business continuity) and Legionella.

• The provider must ensure their audit and governance systems remain effective

The areas where the provider should make improvement are:

• Review and improve access to appointments and the telephone system.

• Review staff recruitment records to include documenting interviews and inductions undertaken.

• Review the cleaning and disinfection of medical equipment and clinical rooms to include a documented schedule that is monitored.

• Review complaints and significant events periodically in order to identify themes and trends.

• Review clinical audit arrangements to include an audit programme based on national and local priorities to demonstrate quality improvement and ensure audits undertaken are meaningful and relevant to the needs of the practice.

We saw one area of outstanding practice:

• The practice had identified a substantial number of their patients as being carers and had registered them as such so that care and services could be provided taking into account their caring responsibilities.

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 Berrymead Medical Centre on 13 September 2016. The overall rating for the practice was ‘requires improvement’. This was because we judged the practice as ‘requires improvement’ for being safe and for being well-led. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for Berrymead Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 20 February 2017. The inspection was carried out to check that the provider had met the legal requirements we set out following the September 2016 visit. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

Our key findings were as follows:

• Improvements had been made to the governance systems to ensure that the quality of services was assessed, monitored and improved. These included; carrying out a health and safety related risk assessment that included control measures, reviewing the arrangements for clinical audit, the creation of a business continuity plan (emergency contingency plan) to manage unforeseen events or major incidents, improved structure and recording of practice meetings to promote good governance and the dissemination of information.

• The provider had reviewed health and safety related policies and procedures.

• An electrical installation safety test had been carried out.

• A fire safety risk assessment had been carried out and new fire safety checks had been introduced.

• A Legionella risk assessment had been undertaken and control measures were in place to prevent Legionella.

• A practice specific infection control policy and procedure had been implemented.

• The provider had introduced a system to ensure that all prescription pads were stored securely and accounted for.

As a result of the actions taken the practice is now rated as ‘good’ for providing a safe service and a well-led service. Overall the practice is therefore now rated as good.

We also found that the provider had made a number of improvements to the service in response to recommendations we made at our last inspection. These included;

• Improvements in patient access to appointments and the telephone system.

• Staff recruitment records had been improved to include documenting staff interviews and staff induction.

• A documented schedule had been introduced for the cleaning and disinfection of medical equipment and clinical rooms.

• A periodic review of complaints and significant events had been introduced in order to identify themes and trends.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice