Letter from the Chief Inspector of General Practice

We undertook this focused inspection of Dam Head Medical Centre on 5 January 2017 for one area within the key question effective.

We found the practice to be good in providing effective services. Overall, the practice is rated as good.

The practice was previously inspected on 23 February 2016. The inspection was a comprehensive inspection under the Health and Social Care Act 2008. At that inspection, the practice was rated good overall. However, within the key question effective, overview management, monitoring and improving outcomes for people was identified as requires improvement, as the practice was not meeting the legislation at that time; Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014: Good Governance.

We found the following processes were not in place:

• There was no formal system to ensure all patients clinical notes were updated regularly in a timely manner into the clinical computer system.
• The coding within patients records needed to be accurate, up to date and the use of prevalence reporting was in line with guidance to ensure patients outcomes were appropriately reflected in prevalence data.

On this inspection we reviewed a range of documents which demonstrated they were now meeting the requirements of Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014: Good Governance.

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 Dam Head Medical Centre on 23 February 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.
• Patients said they were treated with dignity and respect and they were involved in their care and decisions about their treatment. They felt everyone in the practice went above and beyond to provide a compassionate and caring service.
• 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.
• 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.
• Clinical audits had been carried out with evidence that audits were driving improvement but patient outcomes remained lower than national and CCG average for the locality.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• The practice did not have an active patient participation group (PPG) but were trying to organise a virtual group in order to obtain patient feedback about any ways to improve the service.
• The practice had facilities and was equipped to treat patients and meet their needs.
• The provider was aware of and complied with the requirements of the Duty of Candour.
• Patients’ medical records were kept in both electronic and paper format with no formal processes to maintain consistency.

The areas where the provider must make improvement are:

• Ensure coding within patients records is accurate, up to date and the use of prevalence reporting is in line with guidance to ensure patients outcomes are appropriately reflected in prevalence data.
• Implement a formal system to ensure all patients clinical IT notes are updated regularly in a timely manner into the clinical IT system.

The areas where the provider should make improvement are:

• Introduce a more up to date process for the distribution of medical alerts to clinical staff.
• All practice policies in paper and electronic formats are up to date and identical.
• Implement a Patient Participation Group (PPG) in order to identify and act on patients’ views about the service.
• Check all electrical equipment is safe, for example extension leads.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice