Archived: Eastern Avenue Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Eastern Avenue Medical Centre on 6 January 2017. Overall the practice is rated as requires improvement.

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

• Staff described an effective system to report and investigate significant events and there was an up to date policy in place. However, the practice had documented no significant events in the previous two years.
• Risks to patients were assessed and well managed, including through medicines management and safeguarding processes.
• 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.
• There was evidence of multidisciplinary working to meet the complex needs of patients, including vulnerable young people and those who received palliative care. This included participating in a locality design team to implement new care pathways to reduce hospital admissions.
• Patients provided positive feedback about the caring nature of staff and said they took the time to listen to their concerns. We saw staff treated people with compassion, dignity and respect and involved them in care planning 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.
• There was no central record of which members of staff had a DBS check and the practice had not completed risk assessments to identify if non-clinical staff needed a DBS check.

The areas where the provider must make improvements are:

• Ensure fire safety practices in the surgery adhere to the requirements of the Regulatory Reform (Fire Safety) Order 2005, including in staff training, evacuation policies and building safety.

• Ensure the environment is maintained to appropriate standard that ensures consistent protection from infection risk and the build-up of bacteria. This should be audited on a regular basis.

• Ensure staff who provide chaperone services are properly trained.

• Ensure all clinical staff are aware of systems in place to identify at-risk children and young people.

The areas where the provider should make improvements are:

• Ensure learning from significant events is embedded in practice processes and staff professional development.

• Implement a quality improvement programme which includes audit that staff can use to benchmark standards of practice and drive improvements. This should also be used to ensure the needs of patients with long terms conditions are met.

• Implement and maintain a carer’s register to ensure carer’s are identified and provided with structured support.

• Ensure risk assessments are in place for members of staff who are employed withoutDisclosure Barring Service clearance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice