Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sydenham House Medical Centre on 2 November 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Sydenham House Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 30 August 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 2 November 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• The practice demonstrated that significant events were investigated and discussed thoroughly, actions taken and lessons learnt and disseminated, and that the accuracy of recording of significant events and complaints had been improved.

• The practice demonstrated that clinical audits and re-audits were carried out to drive quality improvement.

• The practice had implemented systems to routinely check the equipment used in emergencies was safe, within its expiry date and fit for purpose.

• The practice were able to demonstrate that that systems and processes to govern activity were effective and identified all areas of risk.

The practice had also taken appropriate action to address areas where they should make improvements:

• The practice had identified 163 patients as carers; in addition to 81 patients who were cared for. Together this constituted approximately 2% of the practice’s list and was an increase of approximately 20% of patients identified since the last inspection.

• The practice demonstrated that there were appropriate recruitment checks for all members of staff including Disclosure and Barring Service (DBS) checks.

• Improvements had been made to ensure that the practice had acted on patient feedback regarding access to services.

• Action had been taken to address the areas of concern identified in respect of infection control in accordance with the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance.

The areas where the provider should make improvement are:

• Continue with their action plan in order to help ensure learning and outcomes from significant events are maintained appropriately.

• Continue to monitor and review the appointment system, in order to ensure improvements are sustained.

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 Sydenham House Medical Centre on 2 November 2016. Overall the practice is rated as requires improvement.

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. However, reviews and investigations were not always thorough enough.
• Risks to patients were assessed and well managed, with the exception of those relating to infection control.

• Data showed patient outcomes were low compared to the national average. Although some audits had been carried out, we saw no evidence that audits were used in order to support quality improvement activity.

• The majority of patients said they were treated with compassion, dignity and respect.

• 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.

• Information about services and how to complain was available and easy to understand. However, there was no evidence to show that improvements were made to the quality of care as a result of complaints and concerns nor that lessons were learnt and shared to prevent instances of a similar nature occurring again.
• Patients said they did not find it easy to make an appointment with a named GP and there was no continuity of care, but urgent appointments were available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients.
• Systems and processes to govern activity were not always effective. In that they had failed to identify that not all staff had received safeguarding training at the relevant level for their role.
• Systems and processes to govern activity were not always effective. In that they had failed to identify infection control and prevention issues, the lack of clinical audit and that complaints and significant events were not always monitored and recorded appropriately.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Ensure that significant events are investigated and discussed thoroughly, actions taken and lessons learnt and disseminated, and to ensure that the accuracy of recording of significant events and complaints is stronger.

• Ensure clinical audits and re-audits are carried out to improve patient outcomes.
• Ensure that systems to routinely check the equipment used in emergencies is safe, within its expiry date and fit for purpose.
• Ensure that systems and processes to govern activity are effective and identify all areas of risk.

In addition the provider should:

• Continue to ensure recruitment arrangements include all necessary employment checks for all staff. Including appropriate Disclosure and Barring Service (DBS) checks.

• Continue to ensure they act upon patient feedback with regard to access to services.

• Revise the system that identifies patients who are also carers to help ensure that all patients on the practice list who are carers are offered relevant support if required.

• Continue to ensure that action is taken to address the areas of concern identified in respect of infection control in accordance with the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice