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Archived: Sedlescombe House Good

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Reports


Inspection carried out on 19 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sedlescombe House on 19 April 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. However there was no robust system for formal dissemination, and recording of the dissemination of, learning points.
  • Risks to patients were assessed and well managed with the exception that the action points contained in the Legionella risk assessment had not yet been addressed and not all staff had completed formal fire safety training.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • All staff had been trained in child safeguarding to the appropriate level for their role. All staff with the exception of one member of the clinical staff could provide evidence of having received training in the safeguarding of vulnerable adults.
  • Patients said they were treated with compassion, dignity and respect 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.
  • Most patients said that they found it easy to make an appointment, 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 and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

To introduce more robust systems for formal dissemination, and recording of the dissemination of, learning points from significant events.

To ensure that the recommendations of the Legionella risk assessment are reviewed and actioned.

To ensure that all staff have received vulnerable adult safeguarding training to the appropriate level and ensure all staff have undergone fire safety training.

The areas where the provider should make improvements are:

To designate and train some members of staff as fire wardens.

To ensure all new staff are risk assessed as to whether they require a DBS check.

To increase the number of patients diagnosed with dementia that are reviewed in a face to face meeting annually.

Assess the reasons for high levels of exception reporting for dementia, mental health, heart failure and cancer patients.

To ensure that all carers are identified and flagged on the records.

To look at ways to improve patient access to telephone and face to face consultations.

To make and retain full records of practice meetings.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice