Archived: Southglade Medical Practice Also known as Southglade Health Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Southglade Medical Practice on 26 September 2017. Overall the practice is rated as inadequate.

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. However, systems for the management of significant events needed to be strengthened to ensure any learning identified was shared with the whole practice team and events were reviewed.

• Although risks to patients were assessed, the systems to address these risks were not implemented well enough to ensure patients were kept safe. This included risk relating to recruitment checks, vaccines management and safety alerts, including those received from Medicines and Healthcare products Regulatory Agency (MHRA).

• Staffing numbers were low with the management and directors working across two practices. There was limited supervision and clinical oversight of some staff.

• At the time of our inspection, the providers had been operating for nine months. Data showed patient outcomes were low compared to the national average. Although some audits had been carried out, these were yet to be repeated when appropriate to observe improvements in patient outcomes.
• The practice sought patient feedback through patient surveys, and patients were currently invited to form a patient participation group as another means of engaging them.
• The practice had a leadership structure in place. However, there was limited clinical oversight and the management of processes needed to be strengthened.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients, including taking appropriate action in respect of vaccine management in line with guidance, recruitment checks and recording of actions taken in response to safety alerts including those issued from the Medicines and Healthcare products Regulatory Agency (MHRA).

• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For example, by ensuring patient records accurately reflect actions taken and advice given when consultations have taken place.

In addition the provider should:

• Review and update procedures and guidance relating to safeguarding training in line with national guidance to assure themselves staff are trained at the appropriate levels.

• Consider sharing learning from complaints with the whole practice team to assure themselves of a consistent approach in future.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate 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 service 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 by adopting our proposal to remove this location or cancel the provider’s registration.

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice