Archived: Falcon Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Falcon Medical Centre on 28 January 2016. Overall the practice is rated as inadequate.

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

• Patients were at risk of harm because systems and processes were not implemented well enough to keep them safe. For example, risks relating to staffing, infection control, the premises, equipment and unforeseen events were not well managed to ensure appropriate mitigating action was taken.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• Appropriate recruitment checks were not consistently in place for staff who worked at the practice.
• We identified infection control risks including the inappropriate storage of outside equipment in treatment rooms.
• Ongoing disputes in relation to the premises meant there were risks to business continuity and maintenance issues going unaddressed. There were no definite plans in place to manage this risk.
• There was a chaotic approach to staff training and some staff undertook roles and responsibilities for which there was limited evidence of supervision and opportunities to maintain and update those role specific skills.
• Staff did not demonstrate a good understanding in their responsibilities to information governance.
• The majority of patients said they were happy with the service they received and that they were treated with dignity and respect.
• Information about how to complain was available but complaints were not consistently well managed.
• Patients found it easy to make an appointment with same day urgent appointments available.

The areas where the provider must make improvements are:

• Ensure robust systems are in place for identifying and managing risks to the service and patients. Including risks relating to staffing, infection control, the premises, equipment and unforeseen events.
• Ensure recruitment arrangements include all necessary employment checks for all staff working at the practice.
• Ensure robust processes are in place for the management of infection prevention and control in the practice.
• Ensure staff receive appropriate support, training and supervision to ensure they are competent for their roles and responsibilities undertaken.
• Review complaints process to ensure complaints are consistently handled in a timely manner.
• Review the business continuity plan to ensure that staff have access to all the necessary information required in the event of disruption to the service.

The areas where the provider should make improvement are:

• Review emergency medicines to ensure they cover potential medical emergencies.
• Establish systems so that all clinical staff can access and have opportunities to discuss with others new and best practice guidance.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The practice will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service.

Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice