11 August 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Limefield Medical Centre
on 11 August 2016. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
- There was an open and transparent approach to safety.
- Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, there were examples of incidents not being documented.
- Data showed patient outcomes were low compared to the national average.
- The practice had a number of policies and procedures to govern activity, but some were overdue a review.
- 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.
- 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 must make improvement are:
- Ensure that there are robust governance arrangements in place so that risks are identidied and managed effectively and ensure all staff are aware of what constitutes as a significant event so that these can be documented correctly.
- The practice needs to ensure that clinical staff are involved in clinical audits.
- The provider must ensure that patient identifiable medical information is securely maintained at all times.
- The provider must ensure all staff have an appraisal, medical indemnity insurance, and that all staff have training relevant to their role including basic life support and safeguarding.
The areas where the provider should make improvement are:
- Consider improving access to emergency medicines so they are accessible to all staff.
- Consider keeping all clinical rooms locked when left unattended.
- Improve record keeping in the practice and consider the need to document daily checks.
- Consider the need for a training spreadsheet/matrix to monitor and identify gaps in staff training.
- Review the PGD (patient group direction) folder to ensure all are signed correctly.
- Review practice policies to ensure they are all up to date and contain the necessary information.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice