You are here

Archived: Silverlock Medical Centre Good

This service is now registered at a different address - see new profile

Reports


Inspection carried out on 10 May 2017

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice


We carried out an announced comprehensive inspection at Silverlock Medical Centre on 21 July 2016. The practice was rated good overall and requires improvement for safe. The full comprehensive report from this inspection can be found by selecting the ‘all reports’ link for Silverlock Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced desk-based review carried out on 10 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 21 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At our previous inspection undertaken on

21 July 2016

, we rated the practice as requires improvement for providing safe services and issued a requirement notice for breaches of regulation 12 of the Health and Social Care Act Regulations 2014 as:

• The practice did not have systems in place to monitor the professional registrations of clinical staff.

• Not all staff had completed essential training in accordance with recommendations and guidelines.

• Risks associated with the spread of common communicable diseases, fire, legionella, equipment and emergencies had not been adequately assessed and mitigated.

In addition to the breaches in regulation we suggested the practice should take the following actions:

• Put processes in place to regularly review and update practice policies.

• Include local safeguarding contacts and practice leads within the practice’s safeguarding policy.

• Improve uptake of breast screening and review procedures used to identify patients with

Coronary Heart Disease.

• Introduce a programme of quality improvement which focuses on improving clinical care.

• Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

• Undertake appraisals for all salaried staff.

The practice is now rated as good for the key question: Are services safe?

Our key findings were as follows:

  • The practice had put in place a system to ensure that regular checks of professional registrations were undertaken.

  • Staff had completed essential training in accordance with recommendations and guidelines including fire safety and infection control.

  • The practice had complied with the recommendations in their legionella risk assessment.

  • All electrical equipment had been tested to ensure that it was safe to use.

  • The practice provided evidence that staff had either been vaccinated against common communicable diseases or supplied risk assessments to justify the absence of immunisations for certain members of staff.

  • The practice had a full complement of emergency medicines which reflected current guidelines and their business continuity plan contained contact information for all members of staff.

In addition:

  • The practice sent us a sample of policies demonstrating that reviews were being completed on a regular basis. The practice’s safeguarding policies for adults and children identified the practice leads and contained information for external contacts within the community.

  • The practice told us that they were using a new breast screening alert on their clinical system to alert clinicians to patients who were eligible for breast screening. The practice also informed us that they provided leaflets both in the surgery and on their website. The practice informed us that they would actively contact patients who failed to attend for their breast screening appointment. There had been an increase in the percentage of females aged 50-70 screened for breast cancer in last 36 months from 48% at our last inspection to 55%. However this was still below the local average of 63% and the national average of 73%.

  • The practice told us that they were using computer software to increase the identification of patients with coronary heart disease (CHD) and provided a search of patients prescribed clopidogrel (medication given to patients who have had a heart attack) where there was no diagnosis of CHD noted on their records.

  • The practice provided evidence of improved clinical performance assessed against key performance indicators set by the Clinical Commissioning Group (CCG) in respect of administration of flu vaccinations and management of long term conditions. All areas assessed showed improvement between 2015/16 and 2016/17 For example patients with hypertension who had blood pressure readings within target range had increased by 7% and the numbers of pregnant women who received a seasonal flu vaccination had increased by 25%. The practice had improved performance in these areas by employing a pharmacist to assist with management of patients with long term conditions and upskilling a receptionist to become a healthcare assistant who delivered 349 flu vaccinations in the last flu season.

  • The practice informed us that they had increased the number of patients on their carers register by 15 patients to 52 (0.8%). The practice had used their seasonal flu campaign to identify patients who act as carers and held an open day in October 2016 which was attended by a local carers support organisation.

  • The practice provided evidence that internal appraisals were being undertaken for salaried clinical staff working at the practice.

However, there were still areas of practice where the provider should make improvements.

The provider should:

  • Continue to review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

  • Continue work to improve uptake of breast screening.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 21 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Silverlock Medical Centre on 21 July 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Although most risks to patients were assessed and well managed some including those associated with infection control, emergency supplies and safety of electrical equipment had not been adequately considered or acted upon.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. However we found that some staff had not completed mandatory training, including safeguarding, infection control and fire safety, at the time of our inspection.
  • 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. Appropriate action was taken on the basis of complaints and concerns.
  • Most Patients said they found it easy to make an appointment with a named GP and 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 clear leadership structure and staff felt supported by management. The practice proactively sought feedback from patients, which it acted on and were open to suggestions for improvements made by staff.
  • 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 that there are processes in place to monitor the professional registrations of clinical staff.

  • Ensure that all staff complete the required mandatory training in accordance with current recommendations and guidelines.

  • Ensure that adequate processes are in place to assess and take mitigating actions against any risk including in respect of staff immunity to common communicable diseases, fire safety, legionella, emergency medicines and portable appliance testing.

The areas where the provider should make improvement are:

  • Ensure that processes are in place for regularly reviewing and updating practice policies.

  • Ensure that safeguarding contacts and leads are designated within the practice’s safeguarding policy.

  • Work to improve uptake of breast screening and review procedures used to identify patients with Coronary Heart Disease.

  • Introduce a programme of quality improvement which focuses on improving clinical care.

  • Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

  • Ensure that the practice’s business continuity plan contains all practice staff contact information.

  • Ensure that all clinical salaried staff receive an appraisal every 12 months.

Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice