Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hazeldene Medical Centre on 3 February 2017. Overall the practice is now rated as good.

The practice had been previously inspected on 21st October 2015. Following this inspection the practice was rated requires improvement with the following domain ratings:

Safe – Requires improvement

Effective – Requires improvement

Caring – Good

Responsive – Good

Well-led – Requires improvement

Our key findings from the most recent inspection were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events with learning outcomes documented.
• Staff had a clear understanding of their roles and responsibilities in line with their job description.
• Infection control processes had been introduced with several audits having taken place with actioned outcomes documented and evidenced.
• 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.
• The practice had developed a programme of continuous quality improvement through clinical and internal audits, and these were used to monitor quality and to make improvements.
• Risks to patients were assessed and well managed.
• There was a clear leadership structure. The practice proactively sought feedback from staff and patients, which it acted on. The practice had an active patient participation group (PPG).
• Patients said they found it difficult to access the practice by the phone. Most patients found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvements are:

• Continue to review the telephone and appointment system action plan, to enhance patient experience of access to appointments.
• Use practice data more effectively to monitor performance in areas of exception reporting.
• Ensure care plan templates themselves are updated.
• Review processes in relation to the repeat prescribing policy, whilst implementing a serial checking process for blank prescriptions.
• Add the full address of the Parliamentary and Health Service Ombudsman(PHSO) to the practice leaflet.
• Install an alert system on the practice entrance, so staff can help wheelchair users to access the building.
• Proactively identify carers.

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 Hazeldene on 21st October 2015.

Overall the practice is rated as requires improvement. We found the practice to be good for providing caring and responsive services. It required improvement for providing safe, effective and well-led services.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Although information about safety was recorded, monitored and appropriately reviewed, the practice did not have a clear process for reporting and acting on significant event audits (SEAs) and near misses
• Patients’ needs were assessed and care was planned and delivered following best practice guidance.
• Urgent appointments were available the same day but not necessarily with a GP of their choice.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• There was a clear leadership structure and staff felt supported by the practice manager.
• The practice had hearing loops, easy read format information and translation facilities.
• Information about services and how to complain was available. The practice sought patients’ views about improvements that could be made to the service, including having a patient participation group (PPG).
• Not all staff had a clear understanding of their roles and responsibilities in line with their job description, understood capacity and consent, received regular appraisals or followed policy and procedure.
• There was an inconsistent approach to infection control, medicines management and waste disposal.

There were areas where the provider must make improvements.

Importantly the provider must:

• Ensure significant events and near misses have a clear process and policy, with a designated lead. Sharing learning from significant events process is implemented and shared with all relevant staff.
• Ensure infection control procedures and audits are fully implemented
• Ensure clinical staff have regular appraisals
• Ensure a safe practice environment is maintained, this includes assessment of all risks associated with legionella.
• Ensure there is a designated lead with a clear protocol for all emergency medication and emergency equipment.

In addition the provider should:

• Embed access and knowledge of all practice’s governance policies and procedures
• All staff have a clear understanding of their role and responsibilities in line with job description.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice