You are here

Reports


Inspection carried out on 3 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr K K Abraham and Dr J Joseph also known as the Felmores Medical Centre on 3 February 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. Patient safety alerts were effectively managed and actioned to identify and manage risks to patients.
  • There was a system in place for reporting significant events. However, this could be improved with more timely recording and better detailed documentation of discussions and decisions.
  • The practice was visibly clean and tidy.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had lead areas and the skills, knowledge and experience to deliver effective care and treatment.
  • Patients reported higher than local and national levels of confidence in the GPs.
  • Comments from patients were positive and they reflected they were cared for by committed staff who showed them patience and empathy.
  • 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.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt valued, trusted and supported by management. The practice sought feedback from staff and patients, which it acted on.

The areas where the provider should make improvement are:

  • Record, investigate and document the dissemination of learning from significant incidents.
  • Maintain individualised cleaning schedules to demonstrate when, where and how rooms and equipment were last cleaned.
  • Update records to ensure they accurately reflect risks and actions taken.
  • Increase clinical audits to inform improvements for patient care.
  • Maintain accurate records of discussions, decisions, and actions taken in meetings.
  • Seek wider views from patients in relation to the services provided and respond to it accordingly.

Professor Steve Field

(CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 1 August 2014

During an inspection to make sure that the improvements required had been made

We carried out this inspection to check that the required improvements to the service, which we identified in January 2014 had been made so as to minimise the risks to patients of unsafe or unsuitable care or treatment.

We visited the practice in August 2014. At this time we found that the required improvements to the service had been made.

We saw that patient's views about the care and treatment they received were sought and acted upon where areas for improvement were identified.

There were arrangements for testing the effectiveness of the cleaning and infection control procedures. An audit had been conducted in February 2014 using a recognised audit tool. Where areas for improvements had been identified these had been addressed.

Medicines used to treat patients were regularly checked to ensure that there were sufficient supplies that were in date and fit for use.

There were arrangements for ensuring that staff were made aware of incidents where things went wrong and that there was learning from such incidents so as to minimise recurrences.

During our visit we found that there were appropriate arrangements to protect patients from the risks of unsafe or inappropriate care and treatment because the services provided were monitored and improved where required.

Inspection carried out on 29 January 2014

During a routine inspection

We spoke with three people who used the surgery. One person told us, “The receptionists are good they listen to what you need.” Another person said, “When you get here it is fine, but sometimes it is hard to get an appointment.”

The people we spoke with said they were involved in decisions about their care and treatment. One clinician told us, “I find out what the patient wants to do and go through the options and discuss them. It is their choice, but I would recommend.”

There was a system for monitoring the health needs of people with long term conditions. One person said, “They are very good at monitoring. They don’t let (relative) slip through the net.”

We spoke with four members of staff. We found that each had received an annual appraisal and training applicable to their job role. One member of staff we spoke with said, “I learn through others and ask if I need to know anything.”

The provider had a fire safety audit undertaken by an external organisation and we saw that improvements had been made in response to this.

We saw that significant events were identified and action plans agreed. However some of the actions agreed had not been implemented. For example, we found out of date medicines in the refrigerator.

There was a complaints procedure in place and we saw that complaints were investigated. One member of staff told us, “I would tell people to complain via the practice manager.”

CQC Insight

These reports bring together existing national data from a range of indicators that allow us to identify and monitor changes in the quality of care outside of our inspections. The data within the reports do not constitute a judgement on performance, but inform our inspection teams. Our judgements on quality and safety continue to come only after inspection and we will not make judgements on data alone.


Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.