Archived: Dr Stephen Fletcher Also known as St Andrew's Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Stephen Fletcher at Greenhill Park Medical Centre on 28 October 2014. The practice was temporarily operating from this address having been required to move from their original premises at 125 High Road Willesden due a rodent issue and then the building being deemed unfit to provide medical services by NHS England.

At the time of our inspection the administration team had only recently moved into the Greenhill Park Medical Centre and many administration records were held in storage waiting to be unpacked when space to accommodate the volume was accessible. As a result, we carried out a second inspection on 30 March 2015 to review documents and information that had not been available at the time of our first visit.

Overall the practice is rated as requires improvement.

Specifically, we rated the practice as ‘requires improvement’ for providing safe, responsive and well led services, ‘inadequate’ for providing effective services and ‘good’ for providing caring services. We rated the practice as ‘requires’ improvement for providing services for older people, people with long term conditions, families, children and young people, working age people, people whose circumstances may make them vulnerable and people experiencing poor mental health.

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

• The practice had insufficient leadership capacity.
• There were some procedures for monitoring and responding to risk. For example, infection control audits were carried out and clinical staff had received up to date safeguarding training.
• Disclosure and Barring Service (DBS) checks had not been completed for all administration staff who may be called upon to act as a chaperone.
• Procedures were in place for recording and reporting significant incidents.

• The practice followed current best practice guidelines when planning patient care.
• Patients said they were treated with kindness, dignity and respect.
• Patients were generally satisfied with the appointment system but dissatisfied with the late running of appointments.
• The practice gathered feedback from patients through the Friends and Family Test and the National GP patient survey, however they did not have a patient participation group.

The areas where the provider must make improvements are:

• Improve uptake rates of cervical screening.
• Improve uptake rates of child immunisations.
• Ensure that the care plan programme for frail elderly patients or complex need patients is achieved.
• Notify the CQC of any change that affects registration including location change.

In addition the provider should:

• Ensure Disclosure and Barring Service (DBS) checks are undertaken for all administration staff who may be required to undertake chaperone duties at the practice.
• Ensure all staff who undertake chaperone duties are suitably trained.
• Document in patient records when a chaperone has been involved.
• Review staff recruitment files to ensure that they are consistently maintained.
• Take action to address late running of appointments. This had occurred fairly regularly at the practice and affected patients’ experience of the service.
• Provide clear information for patients about the length of any likely delays to appointments and changes to service provision.
• Review practice information leaflets to ensure that up to date information is provided including current staff, practice appointment arrangements and on line services.
• Formalise the practice vision and values and share these with patients and staff.
• Review all protocols and policies in place to ensure that they are accurate and up to date.
• Ensure that all staff members receive an annual appraisal and support to develop in their role.
• Pro-actively recruit and engage Patient Participation Group (PPG) members.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice