Shepperton Medical Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Shepperton Medical Practice on 14 December 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the December 2016 inspection can be found by selecting the ‘all reports’ link for Shepperton Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 12 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 14 December 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good. At our previous inspection on 14 December 2016, we rated the practice as requires improvement for providing well-led services as the processes for managing risk were not clear. At this inspection we found that it was unclear how effective the processes for managing risk were. Consequently, the practice is still rated as requires improvement for providing well-led services.

Our key findings were as follows:

• Risks were assessed and well managed in some areas, however there were some gaps where risk assessments had not been carried out or completed thoroughly.
• All clinical staff had checks with the Disclosure and Barring Service (DBS).
• There was an overview of training within the practice and all appropriate training had been completed.
• All staff had a record of an annual appraisal and a personal development plan.
• The practice was proactively monitoring QoF performance and exception reporting, and had a plan in place to increase the proportion of patients with dementia receiving an annual review.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure that risk management documents are completed by an appropriate person for all relevant areas, including control of substances hazardous to health, with clear action plans of mitigating actions.
• Ensure that they are aware of the risks identified by external risk assessments and that appropriate mitigating actions have been taken.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Shepperton Medical Practice on 14 December 2016. Overall the practice is rated as requires improvement.

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

• Risks to patients were assessed and well managed in some areas although there were some gaps in the availability of records or where risk assessments had not been carried out.
• The practice did not have risk assessments available in relation to which roles should be subject to Disclosure and Barring Service (DBS) checks, Control of Substances Hazardous to Health (COSHH) and general health, safety and security of the premises.
• Data showed patient outcomes were mixed when compared to the national averages and exception reporting was higher than average in relation to mental health and chronic obstructive pulmonary disease (COPD) performance.
• The proportion of patients with dementia who had received an annual review was 10% lower than the national average.
• Not all staff had evidence of completed DBS checks on file, including some clinical staff.
• Not all staff had received an appraisal in the last 12 months and there were gaps in staff training relating to safeguarding, fire safety and infection control.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Patients received an apology when things went wrong.
• Audits were used to drive improvements in patient outcomes.
• Patients said they were treated with compassion, dignity and respect and satisfaction in relation to the national GP patient survey was high in comparison to local and national averages.
• Patient feedback about difficulties getting through by phone was acted upon in conjunction with discussions with the patient participation group (PPG).
• The practice identified which patients were carers and provided information, advice and additional support.
• There was evidence of an effective system for dealing with complaints and we saw that action was taken and learning was identified and shared.

The areas where the provider must make improvements are:

• Ensure that risk management documentation relating to the building is available on site and that risk assessments are undertaken for all relevant areas including general health and safety and security.
• Ensure a risk assessment is carried out to identify which roles will be subject to a DBS check and ensure that relevant staff have DBS checks held on file.
• Ensure that training logs are up to date and that all staff have regular appropriate training in order to carry out their role.
• Ensure that all staff have a record of an annual appraisal and personal development plan on file.

In addition the provider should:

• Ensure that action is taken to improve QOF performance and reduce exception reporting.
• Improve the proportion of patients with dementia receiving an annual review.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice