Potteries Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Potteries Medical Practice on 10 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 and an effective system in place for reporting and recording significant events. However regular reviews of significant events had not been carried out to identify trends.

• Most staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

• Patients were positive about their interactions with staff and said they were treated with compassion, dignity and they were involved in decisions about their care.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

• Risks to patients were not always assessed and well managed; there was a lack of overview of safety systems such as legionella checks, gas safety checks, fire drills and staff recruitment processes.

• Urgent appointments were available on the same day. Patients told us they found it easy to get an appointment.

• The practice proactively sought feedback from staff and patients, which it acted on.

• Staff felt valued and supported in their work by the management team.

• Information about how to complain was not readily accessible. The practice had only received verbal complaints but these had not been consistently recorded or analysed to identify any common trends.

• Results from the national GP patient survey showed that patients rated their experiences and satisfaction higher for all but two aspects of care compared with the Clinical Commissioning Group (CCG) and the national averages.

• We saw a number of audits had been completed and results were used to drive improvement.

However, there were areas where the provider must make improvements. The provider must:

• Implement effective systems for identifying, assessing, monitoring and mitigating risks.
• Ensure recruitment arrangements cover all necessary employment checks for all staff employed.
• Risk assess the need for inclusion of atropine within the emergency drugs kit for use in the event of cervical shock when performing a coil fitting as per best practice guidance.
• Ensure that a risk assessment for Legionella is carried out in respect of the building.
• Ensure safety checks are carried out on the gas boiler in accordance with the manufacturer’s instructions.
• Maintain a log of fire tests and carry out regular fire drills.

In addition the provider should:

• Implement an effective process to check that patients on high risk medicines are being monitored before issuing prescriptions.

• Carry out a regular analysis of significant events to identify any common trends, maximise learning and help mitigate further errors.

• Review the arrangements for the storage of patient files and emergency medicines.

• Produce a written risk assessment as to why an Automated External Defibrillator AED is not required.

• Hold clinical and practice meetings on a more regular basis.

• Ensure all staff have an annual appraisal and timely access to training.

• Improve the procedure to log, review, discuss and act on alerts received that may affect patient safety.

• Improve the recording of all complaints received and the identification of trends.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice