Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Redhouse Medical Centre on 12 July 2016, where we rated the practice as requiring improvement overall. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Redhouse Medical Centre on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 7 February 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 12 July 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 had made progress in addressing all areas of weakness identified during the previous inspection in July 2016.
- They had implemented an annual review process to check for any themes emerging from significant events over the year, and also check on the implementation of learning.
- The approach to clinical audit within the practice was developing; however this was still largely reactive. The practice had not yet developed an audit programme to support them in proactive quality improvement.
- We found the practice had improved the approach to handling patient safety alerts, such as those from the Medicines and Healthcare Products Regulatory Agency (MHRA). However, the practice did not maintain a documentary record of the action taken in response to each alert.
- They had implemented improvements in recruitment checks.
- Arrangements had been made to offer appraisals for all staff, including non-clinical staff.
- The practice had addressed those areas we told them they should at the July 2016 inspection. This included arranging training for the practice’s designated infection control lead; replacing window blinds with loop cords for those that did not present a ligature risk; improving arrangements to ensure they maintained the cold chain for temperature sensitive medicines; purchasing paediatric defibrillator pads; and preparing a GP locum induction pack. The practice had also taken steps to develop a patient participation group, but they had not successfully held a meeting of the group yet.
- The vision and strategy for the practice was developing. They had started to develop a business plan to document the future development of the practice.
- The leadership capability and structure within the practice was being developed to ensure it supported the practice going forward.
There are areas where the provider should make improvements. The practice should:
- Continue to develop and strengthen their governance systems to ensure staff are supported to proactively manage and continually improve the quality of the service provided. This includes developing a proactive programme of clinical and non-clinical audit to support quality improvement, further improve patient outcomes and safety of the practice.
- Check the infection control arrangements within the practice are appropriate by carrying out an audit and following up and implementing any improvements identified.
- Maintain a good audit trail of action taken in response to patient safety alerts, including those from the Medicines and Healthcare Products Regulatory Agency (MHRA).
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice