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Archived: Dr Carl Chang Good Also known as Bush Hill Park Medical Centre

The provider of this service changed - see new profile

Reports


Review carried out on 25 October 2019

During an annual regulatory review

We reviewed the information available to us about Dr Carl Chang on 25 October 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 24 May 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Carl Chang (also known as Bush Hill Park Medical Centre) on 30 March 2016. The overall rating for the practice was Requires Improvement. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Dr Carl Chang on our website at www.cqc.org.uk.

At our previous inspection in March 2016, we rated the practice as Requires Improvement for providing safe, effective and well-led services. At this time included amongst the issues we identified, was the practice could not provide sufficient evidence to confirm that clinical staff had specific training to administer vaccines and to conduct cervical screening. In addition, the practice did not have defibrillator and did not have the required mask for a child or the oxygen held at the practice.

This inspection was an announced focused inspection carried out on 24 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 30 March 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. At this inspection, we found that the practice had made improvements to provide safe, effective and well-led services. As a result of these findings, the practice is now rated as Good for providing safe, effective and well-led services.

The change in the ratings for safe, effective and well-led, means that the practice is now rated as Good overall.

Our key findings were as follows:

  • All practice staff had undertaken basic life support training within the last 12 months.
  • The practice had access to a defibrillator. Oxygen held on site had both adult and child masks.
  • Practice policies and procedures had been recently reviewed and updated where required. This included systems for managing incidents and significant events as part of the requirements under the Duty of Candour and a revised business continuity plan.
  • The practice had a system in place to ensure that all emergency medicines held were in date.
  • Clinical staff had undertaken training to ensure competence in administering vaccines and conducting cervical screening.
  • The practice conducted regular fire drills. All staff members had been trained in what to do in the event of a fire.
  • All staff had an appraisal within the last 12 months and there was an induction programme for new staff.
  • The practice had devised a business strategy with proposed plans for the practice over the next five years.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 30 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Carl Chang (known as Bush Hill Park Medical Centre) on 30 March 2016. Overall the practice is rated as Requires Improvement.

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.
  • Risks to patients were assessed with the exception of those relating to medicines management.
  • Data showed patient outcomes were low compared to the locality and nationally. Although two audits had been carried out, there was not enough evidence that audits were driving improvement in performance and patient outcomes.
  • Patients said they were treated with compassion, dignity and respect.
  • Urgent appointments were available on the day they were requested.
  • The practice had a number of policies and procedures to govern activity, but some were overdue a review.
  • The practice had proactively sought feedback from patients and had an active Patient Participation Group.

The areas where the provider must make improvements are:

  • To ensure all new staff are aware of their responsibilities and how the practice runs and to ensure that all established staff have regular appraisals.
  • All staff must have basic life support training.
  • Assess the risk of not having access to a defibrillator and ensure that oxygen held at the practice has the appropriate masks available.
  • Ensure that staff have specific training for administering vaccines and to perform cervical screening in accordance with good practice.
  • Regularly review stock of emergency medicines to ensure that all medicines are in date.

In addition the provider should:

  • Review and update practice policies, procedures and guidance.
  • Have business continuity plans to support the practice in the event of an emergency.
  • Initiate a programme of regular fire drills.
  • Obtain a Control of Substances Hazardous to Health (COSHH) assessment.
  • Ensure that patients are aware of the availability of chaperones.
  • Devise systems to monitor the usage of prescription pads held at the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice