Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Sunbury Health Centre Group Practice on 8 December 2015. The practice had been rated as good for caring and well-led, however, required improvement in safe, effective and responsive domains and therefore had an overall rating of Requires Improvement. After the comprehensive inspection, the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:-
- Improve processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.
- Ensure systems are in place for disseminating information received from Medicines and Healthcare products Regulatory Agency to all appropriate staff members.
- Ensure Disclosure and Barring service (DBS) checks are in place for those staff members that acted as chaperones.
- Ensure that blank prescription forms are tracked and stored securely within the practice.
- Ensure that all staff have completed relevant training as required by the practice for basic life support, fire safety, infection control, information governance and safeguarding vulnerable adults and ensure evidence of this is recorded.
- Ensure that systems and processes are reviewed to complete referrals in a timely manner.
- Carry out regular fire drills.
- Ensure staff have regular appraisals.
- Ensure the complaints policy contains information regarding advocacy or the Ombudsman for patients to refer to.
We undertook this announced focused inspection on 14 July 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. The provider was now meeting all requirements and are rated as Good under the safe, effective and responsive domains.
This report only covers our findings in relation to those requirements.
- There were robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses. Non-clinical staff also raised significant events and learning from all events was discussed with all team members.
- Information received from Medicines and Healthcare products Regulatory Agency was disseminated to all appropriate staff members and stored on the practices computer system.
- Disclosure and Barring Service (DBS) checks and training was in place for those staff members who acted as chaperones.
- There was a robust system in place for the tracking and secure storage of blank prescription forms within the practice.
- Staff had completed relevant training as required by the practice for basic life support, fire safety, infection control, information governance and safeguarding vulnerable adults and we saw training certificates to evidence this.
- A new referral system was in place which ensured that all referrals made by the GP were completed within four days. We checked the process and found that the practice no longer had a backlog and was working on referrals for the previous day and the day of the inspection only.
- The practice had carried out a fire drill, which had been discussed and evaluated with action points recorded. Six monthly fire drills were planned.
- A new appraisal form and system was in place for appraisals. Staff had received an appraisal, which recorded training requests, objectives and career development.
- The complaints information had been updated. It included information for patients in relation to advocacy and the ombudsman. Posters in the waiting area, leaflets and the website had also been updated with this information.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice