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Inspection carried out on 5 April 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 Grove Hill Medical Centre on 31 August 2016. The overall rating for the practice was good. However, we identified breaches of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided well-led services. Consequently the practice was rated as requires improvement for being well-led. The full comprehensive report from the 31 August 2016 inspection can be found by selecting the ‘all reports’ link for Grove Hill Medical Centre on our website at www.cqc.org.uk.

After the comprehensive inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to;

  • Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014

- good governance.

The areas identified as requiring improvement during our inspection in August 2016 were as follows:

  • Ensure that a Legionella risk assessment is completed and that any issues identified are resolved and that water temperature checks are completed correctly.
  • Ensure that infection control audits are fully completed and that the issues identified and actions in place to resolve them are clear.
  • Ensure sufficient quality assurance processes are in place, including implementing a structured programme of repeat cycle clinical audit.
  • Ensure there is a formal and coordinated practice wide process in place for how staff access guidelines from NICE and use this information to deliver care and treatment.
  • Ensure that at all times sufficient processes are in place and adhered to for the management and review of results received from secondary care services.

In addition, we told the provider they should:

  • Ensure that all staff employed are supported by completing the essential training relevant to their roles, including safeguarding adults training.
  • Take steps to ensure that hot water temperatures at the practice are kept within the required levels.
  • Ensure that at least one piece of photographic proof of identification is included in the personnel file of each member of staff.
  • Ensure that checks on all emergency equipment are documented and that the Resuscitation Council guidelines displayed at the practice are up to date.
  • Continue to identify and support carers in its patient population by providing annual health reviews.
  • Ensure that, where practicable and appropriate, all reasonable adjustments are made for patients with a disability in line with the Equality Act (2010).

We carried out an announced focused inspection on 5 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches of regulation that we identified in our previous inspection on 31 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key finding on this focused inspection was that the practice had made improvements since our previous inspection and were now meeting the regulation that had previously been breached.

The practice is now rated as good for providing well-led services.

On this inspection we found:

  • Clinical audit demonstrated quality improvement.
  • Appropriate Legionella and water temperature management processes were in place. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
  • The latest infection control audit was fully completed and the issues identified and any actions in place to resolve them were clearly detailed.
  • A coordinated practice wide process was in place to ensure that staff had access to National Institute for Health and Care Excellence (NICE) guidelines and used this information to deliver care and treatment that met people’s needs.
  • Sufficient processes were in place and adhered to for the management and review of results received from secondary care services.

Additionally where we previously told the practice they should make improvements our key findings were as follows:

  • All staff had completed adult safeguarding training.
  • Personnel files contained appropriate photographic proof of identification.
  • A documented log of the weekly checks on the defibrillator was available and well completed.
  • Up to date Resuscitation Council guidelines were displayed at the practice and staff were aware of any changes from the previous version.
  • Sufficient arrangements were in place to identify carers in the practice’s patient population and offer them an annual health review.
  • A portable hearing loop was provided.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 31 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Grove Hill Medical Centre on 31 August 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.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients were positive about the standard of care they received and about staff behaviours. They said staff were helpful, caring and professional. They told us that their privacy and dignity was respected 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • 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.
  • Staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • There were some weaknesses in the governance arrangements at the practice that, although not placing patients at risk of significant harm, could be strengthened to ensure the delivery of high quality care.

The areas where the provider must make improvements are:

  • Ensure that a Legionella risk assessment is completed and that any issues identified are resolved and that water temperature checks are completed correctly.
  • Ensure that infection control audits are fully completed and that the issues identified and actions in place to resolve them are clear.
  • Ensure sufficient quality assurance processes are in place, including implementing a structured programme of repeat cycle clinical audit.
  • Ensure there is a formal and coordinated practice wide process in place for how staff access guidelines from NICE and use this information to deliver care and treatment.
  • Ensure that at all times sufficient processes are in place and adhered to for the management and review of results received from secondary care services.

The areas where the provider should make improvements are:

  • Ensure that all staff employed are supported by completing the essential training relevant to their roles, including safeguarding adults training.
  • Take steps to ensure that hot water temperatures at the practice are kept within the required levels.
  • Ensure that at least one piece of photographic proof of identification is included in the personnel file of each member of staff.
  • Ensure that checks on all emergency equipment are documented and that the Resuscitation Council guidelines displayed at the practice are up to date.
  • Continue to identify and support carers in its patient population by providing annual health reviews.
  • Ensure that, where practicable and appropriate, all reasonable adjustments are made for patients with a disability in line with the Equality Act (2010).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice