Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Thornhill Lees Medical Centre on 9 August 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.
• Risks to patients were assessed and well managed.

• The practice carried out regular medicines audits, with the support of the local CCG pharmacist, to ensure prescribing was in line with best practice guidelines for safe prescribing. The pharmacist told us that the GP was an effective prescriber who engaged well on projects to improve prescribing.
• 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.
• 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. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they 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 practice offered extended hours appointments on a Monday, Thursday and Friday evening until 7.30pm for working patients who could not attend during normal opening hours.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had extensively renovated the branch surgery and installed an accessible bathroom at the main surgery. A lift was installed at the branch practice and all services at the main surgery were at ground floor level.
• 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.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvements are:

• Review the arrangements in place for the periodic testing of all portable electrical equipment.
• Review the labelling arrangements for clinical waste bags to be able to identify the source of the waste in line with current legislation and guidance.
• Assess whether non-clinical long standing members of staff should have DBS checks.
• The practice should risk assess the need for emergency oxygen to be kept on the premises.
• Provide safeguarding training for the healthcare assistant to level two.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out this unannounced inspection because we had received some information of concern around medicines management.

We focused the majority of our inspection at Thornhill Lees Medical Centre but also visited the Savile Road Surgery.

We spoke with three patients following our inspection. The patients we spoke with were happy with the service they received from the practice. Comments included:

“Yes I have had no problems whatsoever. In fact they will all be good marks as I’m quite pleased with them.”

“I ring them up and they offer me an appointment. They’re pretty good with that too. I’ve had a poorly time this last three or four years and I’m quite happy with the treatment that I’ve had.”

“I haven’t had a complaint. No way, I’ve been going for long enough.”

We saw that the practice encouraged feedback from patients’ through a comments box on reception. We were also able to review feedback from patient surveys.

We found that the practice had a safeguarding policy in place which contained details of external contacts. However this was not easily accessible at the time of our inspection due to the practice manager being on annual leave.

We saw that there were processes in place to check medication stored within the practice. However when we looked at the annual record of expiry dates we saw that Adrenalin held in stock had already passed the expiry date.