Archived: The Sollershott Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Sollershott Surgery on 12 May 2016. 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, reviews and investigations were not thorough enough. Lessons learnt from incidents and near misses were not shared within the practice.
• Risks to patients were assessed in most areas but identified mitigating actions were not implemented.
• Complaints of a clinical nature were not investigated by a clinician and learning from complaints had not been shared with practice staff.
• The practice had not sought feedback from patients via their virtual patient participation group (PPG).
• Data showed patient outcomes were comparable to the local and national averages.
• Patients said they were treated with compassion, dignity and respect.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Systems and processes must be established and operated effectively to ensure good governance.

• Ensure blank prescriptions are stored securely at all times and there is a system in place to monitor the use of the blank prescription forms.

• Ensure that all staff employed are supported by receiving appraisals and complete the training essential to their roles.

• Implement the actions identified in the risk assessment relating to fire safety, including staff training and fire drills.

• Complete a risk assessment to identify mitigating actions for not having a defibrillator on the premises.

• Ensure a legionella risk assessment is completed by a person competent to carry out the task.

• Investigate safety incidents formally and ensure that lessons learnt are shared with practice staff.

• Implement a process to ensure that complaints are investigated by the appropriate person, monitor complaints for trends and share learning from complaints with the practice staff.

• Implement systems and processes to ensure there is effective communication with practice staff.

• Engage with the virtual PPG to gather feedback from patients.

In addition the provider should:

• Review the business continuity plan and update the contact numbers.

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