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Archived: Ravenscroft Medical Centre Good

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Reports


Inspection carried out on 10 August 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Ravenscroft Medical Centre on 14 and 19 July 2016. During the inspection we identified that governance arrangements did not always operate effectively in that there was limited evidence of sharing learning from significant events and also risks and performance were not always effectively managed (The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Ravenscroft Medical Centre on our website at www.cqc.org.uk).The overall rating for the practice was requires improvement.

An announced comprehensive inspection was undertaken on 10 August 2017. Overall the practice is now rated as good.

Our key findings of our inspection of Ravenscroft Medical Centre were as follows:

  • Action had been taken to ensure that significant event reviews and investigations were sufficiently thorough. For example, meetings regularly took place to share learning from significant events and to take steps to maintain or improve patient safety.
  • Action had been taken to ensure that governance arrangements operated effectively. For example, staff routinely met to identify, monitor and take mitigating actions against risks.

  • Action had been taken to improve arrangements for the safe storage of vaccines. For example, the practice had revised its systems for recording fridge temperature readings.
  • Staff were aware of current evidence based guidance.
  • Staff had the skills and knowledge to deliver effective care and treatment.

  • Data from the national GP patient survey showed that patients rated the practice higher than others on the extent to which they were treated with dignity and respect; and the extent to which they were involved in decisions about their care and treatment.

  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.

  • Patients we spoke with 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 staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour.
  • Practice management arrangements promoted an open approach to safety which facilitated the delivery of safe and high quality care.

The areas where the provider should make improvement are:

  • Continue to monitor and take action as necessary to improve cervical screening and child immunisation uptake rates.

  • Ensure that water temperature monitoring takes place to control the risk from Legionella (a term for a particular bacterium which can contaminate water systems in buildings).

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 14 and 19 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Ravenscroft Medical Centre on 14 July and 19 July 2016. Overall the practice is rated as requires improvement.

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

  • Significant event reviews and investigations were not always sufficiently thorough. For example, there was limited evidence that meetings took place to share learning from significant events and take steps to maintain or improve patient safety.

  • We identified concerns with the arrangements for storing vaccines in that the practice could not provide fridge temperature records prior to November 2015. Given our concerns, we notified Public Health England of our findings.  Shortly thereafter, we were advised that no further action was required.
  • Governance arrangements did not always operate effectively. For example, there was limited evidence that staff routinely met to identify, monitor and take mitigating actions against risks.

  • Clinical audits were being used to drive improvements to patient outcomes.

  • Data showed that with the exception of cervical screening uptake, most patient outcomes were above the national average.

  • Data from the national GP patient survey showed patients rated the practice higher than others on most aspects of care.

  • 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.

  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

The areas where the provider must make improvements are:

  • Ensure that cervical screening uptake is monitored and action taken as necessary to improve performance.
  • Ensure that the vaccines fridge temperatures are being regularly monitored to ensure the vaccine’s effectiveness.
  • Ensure that a risk assessment is undertaken of its decision not to keep a defibrillator on the premises.
  • Ensure that control of substances hazardous to health risk assessments take place.
  • Ensure that annual fire risk assessments take place.
  • Ensure that there are systems in place to assess, monitor and mitigate risks relating to the health, safety and welfare of service users (for example, to ensure annual calibration of clinical equipment).

In addition the provider should:

  • Investigate safety incidents thoroughly, including ensuring that staff learning is shared and documented at clinical meetings and that this involves all relevant people.

  • Review systems in place for identifying and supporting carers.

Please note that Quality and Outcomes Framework (QOF) data referred to in this report relates to unverified data provided by the practice on the day of our inspection. QOF is a system intended to improve the quality of general practice and reward good practice.

Ravenscroft Medical Centre also operates a branch location which is open three hours per day for approximately thirty nine weeks per year. Patient registration is restricted to students of Middlesex University.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice