Archived: Conway Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Conway Medical Centre on 11 and 12 January 2017. Overall, the practice is rated as good, however it is rated as requires improvement for the safe domain. Our key findings across all the areas we inspected were as follows:

• The practice had recently reviewed and updated the majority of their policies and procedures. A signatory sheet had been introduced to ensure all staff signed to say they had read and understood them.

• Staff understood their responsibilities to raise concerns. We saw evidence of investigation, actions and shared learning from those incidents which had been reported. However, it was unclear whether all incidents and near misses had been reported and recorded in the absence of a permanent practice manager. We were assured that systems had been recently reviewed to ensure all incidents were being recorded and staff had been reminded to report any incidents or near misses.
• Some risks to patients were assessed and well managed. However, it was not clear how patient safety alerts had been dealt with prior to the locum practice manager being in post. A system had since been implemented to action all relevant alerts.

• There were health and safety risk assessments in place, including fire risk. Not all staff were up to date with fire safety training. However, we were assured that staff knew what to do in such an event and that training had been arranged for staff to complete by the end of January 2017.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• A health trainer was available in the practice on a weekly basis, to provide additional support for patients regarding lifestyle choices, health advice and signposting to other appropriate services.
• The most recently published national GP patient survey results showed patient satisfaction rates with the practice were lower than average. However, a practice based survey and patient comments we received on the day, were positive about the service and care they received.
• Data showed patient outcomes were in line with local and national averages.
• 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.
• Staff had a good understanding of their practice population and the majority were multilingual in languages suitable to the needs of their patients.
• We saw that staff were dedicated to improving the quality of care and were positive about any changes which were being made to achieve this.

The areas where the provider must make improvements are:

• Ensure all Patient Group Directions (PGDs) are signed by the nursing staff who are administering vaccines and medicines; in line with the latest legislation.

In addition the provider should:

• Support staff to keep up to date with mandatory training in accordance with current guidelines.
• Improve record keeping from practice, clinical and multidisciplinary meetings.
• Continue to implement, review and maintain the systems and processes which are used to govern the practice and ensure the safety of patients.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice