Archived: Brookfield Surgery, Valley Health Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Brookfield Surgery on 24 February 2016. Overall the practice is rated as requires improvement.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. There was a system in place for reporting and recording significant events.
• Risks to patients were assessed and managed, with the exception of those relating to recruitment checks and where responsibilities were shared with the landlord of the premises.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. However, patient records may not always be up to date as there were a number of documents waiting to be electronically filed. We did not find any evidence patient care had been compromised due to this.
• Staff had the skills, knowledge and experience to deliver effective care and treatment although training records were not up to date.
• Feedback from patients about their care was consistently and strongly positive. 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 lack of management monitoring where responsibilities for matters relating to health and safety were shared with the landlord
• There was a clear leadership structure and staff felt supported by management, although they did not feel involved or engaged to improve how the practice was run.
• The practice proactively sought feedback from patients and had an active patient participation group.
• The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

• Ensure recruitment arrangements include all necessary employment checks for all staff prior to employment.
• Review joint health and safety procedures of the premises to ensure these identify all risks and control measures and ensure these are implemented.
• Ensure records for the management of the practice, such as patient records and training records, are up to date and complete.
• Improve staff involvement in practice development and improvement.

In addition the provider should:

• Record action taken in response to medical alerts to ensure a complete audit trail.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice