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Inspection carried out on 6 February 2019

During a routine inspection

We carried out an announced comprehensive inspection at Kenwood Medical Centre on 6 February 2019 as part of our inspection programme.

At the last inspection in February 2018 we rated the practice as requires improvement for providing safe, caring, responsive and well-led services because:

  • The practice management did not have sufficient oversight of the functions of the locum practice nurses.
  • There was no clear process on the management of blank prescriptions held at the practice.
  • Staff records were not kept up-to-date and safety alerts were not being received in the practice.
  • The practice did not act on low patient satisfaction survey results. At this time, the practice was not aware of their most recent national patient survey results.

At this inspection, we found that the provider had satisfactorily addressed these areas.

We based our judgement of the quality of care at this service is on a combination of:

  • What we found when we inspected
  • Information from our ongoing monitoring of data about services and
  • Information from the provider, patients the public and other organisations.

We have rated this practice as good overall.

We rated the practice as good for providing safe services because:-

  • The practice had systems and processes in place to keep patients safe.
  • Lessons were learned and improvements were made when things went wrong.
  • The practice could demonstrate that it received and distributed among relevant staff safety alerts.

We rated the practice as good for providing effective services overall and across all the population groups because:-

  • We saw that clinical staff assessed patient needs and delivered care and treatment in line with current legislation.
  • The practice conducted quality improvement activities to help monitor the care and treatment provided.
  • Clinical staff had the relevant skill, knowledge and experience to carry out their role.

We rated the practice as good for providing caring services because:-

  • The practice gave timely support and information to patients.
  • The practice respected patient’s privacy and dignity.
  • The had improved their knowledge regarding the numbers of carers within the practice. Staff were active in identifying carers.

We rated the practice as good for responsive services overall and across all the population groups because:-

  • Complaints were handled in line with recognised guidance. The practice learned lessons and acted to improve services as a result of complaints received.
  • The practice offered extended hours surgery three times a week.
  • Patients had access to booking appointments online as well as requesting repeat prescritions.

We rated the practice as good for providing well-led services because:-

  • The practice leaders had a vision and strategy for delivering quality care.
  • Practice leaders looked after the safety and well-being of all staff at the practice.
  • There was clear lines of responsibility, roles and systems to support good governance and management.
  • The practice engaged regularly with their patients through their patient participation group.

The areas where the provider should make improvements are:-

  • Review the practice online presence.
  • Review how receipt of safety and medicine alerts distributed within the practice are acknowledged.
  • Review the frequency and recording of checks on the practice defibrillator.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 21 February 2018

During a routine inspection

This practice is rated as Requires Improvement overall.

We carried out an announced comprehensive inspection at Kenwood Medical Centre on 21 February 2018. Overall the practice is rated as Requires Improvement.

At this inspection we rated the practice as follows for the key questions :-

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) – Requires Improvement

We carried out an announced comprehensive inspection at Kenwood Medical Centre on 21 February 2018. This inspection was a full comprehensive first rating inspection of this provider.

At this inspection we found:

  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • There was no regular oversight by the lead GP of the administrative functions provided at the practice.
  • Staff encouraged and supported patients to be involved in monitoring and managing their health.
  • The National GP Patient Survey showed that patient satisfaction scores with the practice was below the national average.
  • The practice learned lessons from individual concerns and complaints, and used this information to improve services at the practice.
  • Staff files/records did not contain relevant documentation such as references, job descriptions or curriculum vitaes.
  • We saw evidence that clinical audits had a positive impact on quality of care and outcomes for patients.
  • The practice took account of the needs the practice population and offered appointments from 7:30 daily.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

The areas where the provider should make improvements are:

  • To review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is available to them.
  • Review systems relating to the monitoring of uncollected prescriptions kept at the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice