Archived: Dr BPC Peiris' Practice Also known as Alderwood Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr BPC Peiris’ Practice on 12 April 2016. Overall the practice is rated as requires improvement.

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. Reviews and investigations were thorough and patients always received an apology.
• Risks to patients were assessed but not always well managed. This was in relation to risks which had not been addressed from a fire risk assessment, failure to conduct a risk assessment for the control of substances hazardous to health, and recruitment procedures which were not robust.
• A non-clinical member of staff informed us they updated medical records for patients who had received vaccinations in instances where nurses had failed to, and without specific instructions from the nurse. The practice had not put any systems in place to prevent this from happening again.
• A GP did not document instances where patients had declined a chaperone.
• Data showed patient outcomes were comparable to or below national averages.
• We saw evidence that audits were driving improvements to patient outcomes.
• All of patients we spoke with said they were treated with compassion, dignity and respect; they felt cared for, supported and listened to.

• Information about services was available but there was no information on avenues of support available to carers.

• Patients reported that although urgent appointments were usually available the same day, they had faced difficulties getting pre-bookable appointments.

• The practice had a number of policies and procedures to govern activity, but there was no policy for safeguarding adults.
• There was a clear leadership structure and staff felt supported by management but not all of them felt their views were valued.
• The practice proactively sought feedback from patients, which it acted on.
• Governance arrangements were not effective enough to support the practice’s vision to provide high quality care.

The areas where the provider must make improvements are:

• Ensure clinical staff maintain a contemporaneous record of the care and treatment provided to every service user, and implement processes to investigate any instance where this does not occur.

• Ensure all risks from the fire risk assessment are addressed, and there is a process for reviewing the risk assessment at appropriate intervals; ensure fire alarm systems are tested regularly and these tests are documented.

• Ensure recruitment arrangements include all necessary employment checks for all staff.

In addition the provider should:

• Ensure there is a defibrillator available, or a risk assessment which adequately mitigates the need to have one.

• Improve processes in place for monitoring vaccines fridge temperatures.

• Ensure all clinical staff make a record of instances where patients decline to have a chaperone present during consultations or procedures.

• Ensure there is a policy and named lead for safeguarding adults.
• Review performance for diabetes related indicators, and for exception reporting, and make improvements.
• Ensure a sharps injury protocol is displayed in consulting and treatment rooms.
• Ensure the business continuity plan is sufficiently comprehensive.

• Ensure appraisals are completed annually and appraisal forms are completed appropriately.

• Consider including safeguarding, infection control, and fire safety to the induction process for new staff.

• Improve access to appointments for patients, and ensure translation services are advertised in a format patients can understand.
• Improve the system for identifying carers, and ensure there is sufficient written information available to support carers on the patient list.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice