Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 20 October 2015. A breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to;

• Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – safe care and treatment.

• Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – good governance.

• Regulation 19 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – fit and proper persons employed.

We undertook this focused inspection on 9 June 2016, to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting 'all reports' link for The Avenues Medical Centre on our website at www.cqc.org.uk

From the inspection on 20 October 2015, the practice were told they must:

• Improve recruitment arrangements and all necessary employment checks for all staff.

• Complete risk assessments for the full environment. Additionally, blinds on the windows and the blind loop cords were safe and secured as these could potentially be a choking hazard to small children when attending the surgery. Refer to Estates and Facilities Alert (EFA/2015/001 issued 26 January 2015).

• Implement a system of reporting incidents without fear of recrimination and monitor learning from outcomes of analysis, patterns and trends of incidents.

• Monitor the prevention and control of infection.

• Complete health and safety risk assessments on the environment to reduce the risk of harm to patients.

• Review the practice facilities in respect of disabled access.

• Ensure systems are in place for identifying and monitor the completion of training for all staff in order for them to carry out their duties effectively and safely.

• Implement a clear defined leadership structure and business planning arrangements to provide effective succession planning.
• Complete risk management and assessments for the access and safety of the building premises for patients with limited mobility.

We found that on the 9 June 2016 the practice now had improved systems in place.

• Records we looked at confirmed that staff recruitment checks had been completed.

• We saw that health and safety risk assessments had been completed on the practice premises and environment including for patients with limited mobility and assessment adjustments to the blinds.

• The practice policy and procedures had been updated to include a mechanism for all staff to record incidents and concerns without fear of recrimination and staff we spoke to were clear about their duties in relation to this.

• We saw that the practice had completed hand washing audits and cleanliness checks. Additionally, a recent infection control audit had been commissioned and action points identified. Some of the action points were completed and some were in the process of completion.

• Records we looked at confirmed training for all staff had been updated and a responsible lead member of staff was allocated the duty to monitor training progress.

• We saw records that defined key leaderships roles in the practice and staff we spoke with understood their roles.

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 The Avenues Medical Centre on 20 October 2015.

Overall the practice is rated as requires improvement.

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

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, health and safety risk assessments had not been completed on the environment.

• Actions identified to address concerns with infection control arrangements had not been taken.

• The practice facilities were in need of review in respect of disabled access. The premises did not include lift access to a first floor waiting area and consulting rooms.
• 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.

• Urgent appointments were usually available on the day they were requested.
• The practice had proactively sought feedback from staff or patients.

The areas where the provider must make improvements are:

• Recruitment arrangements must include all necessary employment checks for all staff.

• Risk assessments must be completed for the full environment. Additionally, blinds on the windows and the blind loop cords were long and could potentially be a choking hazard to small children when attending the surgery. Refer to Estates and Facilities Alert (EFA/2015/001 issued 26 January 2015).

• A system of reporting incidents without fear of recrimination and whereby learning from outcomes of analysis, patterns and trends of incidents was not fully implemented.

• There must be mechanisms in place to manage and monitor the prevention and control of infection.

In addition the provider should:

• Systems must be in place for identifying and monitor the completion of training for all staff in order for them to carry out their duties effectively and safely.

• The practice should have a clear defined leadership structure and business planning arrangements to provide effective succession planning.
• The practice should have risk management and assessment in place for the access and safety of the building premises for patients with limited mobility.

• Two GPs we spoke with told us the practice did not have a carers register in place but was something planned for the future.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice