Archived: Victoria Cross Surgery

Letter from the Chief Inspector of General Practice

In February 2016 a comprehensive inspection of Victoria Cross Surgery was conducted. The practice was rated as requires improvement for safe, effective and well led, and good for caring and responsive. Overall the practice was rated as requires improvement. During that inspection we found concerns related to: the investigation and actions following significant events; the recording of discussions and actions during practice meetings; the training for safeguarding children and adults; the child protection register; the security of blank prescriptions; recruitment checks; the system of clinical audit; the mandatory training and appraisals; the governance arrangements for infection control; fire safety arrangements; and legionella risk assessment.

We advised the practice they should: improve the cervical screening uptake and smoking cessation advice uptake; develop and implement a clear action plan to improve the outcomes for learning disabilities patients and patients experiencing poor mental health; and ensure that complaints information is updated.

The report setting out the findings of the inspection was published in March 2016. Following the inspection we asked the practice to provide an action plan detailing how they would improve on the areas of concern.

We visited the practice and carried out an announced focused inspection of Victoria Cross Surgery on 25 August 2016 to ensure the changes the practice told us they would make had been implemented and to apply an updated rating.

We found the practice had made significant improvement since our last inspection on 10 February 2016. At the inspection undertaken in February 2016 we rated the practice as requires improvement for providing safe, effective and well led services. For this reason we have only rated the location for the key questions to which this related. The practice is now rated as good for providing safe, effective and well led services. This report should be read in conjunction with the full inspection report of 10 February 2016.

At this inspection we found:

• Risks to patients were assessed and managed.
• Systems were in place to monitor the outcomes for patients.
• Recruitment and training records were up to date and monitored.
• Significant events were investigated and any actions undertaken and learning shared.

The areas where the practice should make improvements are:

• Ensure an on-going system including audits to monitor and improve outcomes for patients.

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 Victoria Cross Surgery. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for provision of safe, effective and well-led services. It was good for providing caring and responsive services. The concerns which led to these ratings apply to all population groups using the practice.

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. Information about safety was recorded. However, reviews and follow ups of significant events and incidents were not thorough and lessons learned were not always communicated widely enough to support improvement.
• Risks to patients were assessed and well managed in some areas, with the exception of those relating to child protection, safeguarding, infection control, fire safety, legionella risk assessment and tracking of prescriptions. .
• We saw the practice was finding difficult to carry out repeat audits which was making it difficult to identify improvement areas and monitor continuous progress effectively.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Most staff had the skills, knowledge and experience to deliver effective care and treatment. However, some staff had not attended mandatory training.
• The practice had good facilities and was well equipped to treat patients and meet their needs. However, announcements in the waiting area was not always very clear to understand and there was no low level desk at the front reception.
• 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 were available and easy to understand.
• 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 practice was aware of and complied with the requirements of the Duty of Candour.
• The practice had a lack of governance arrangements to enable assessment and monitoring of the service.

The areas where the practice must make improvements are:

• Review the process for investigating and implementing change following incidents and significant events to ensure actions are completed. Improve the recording of discussions and actions during practice meetings.
• Ensure safeguarding children and adults trainings are undertaken by all staff, and child protection register is maintained and continuously monitored.
• Review the management and security of blank prescription forms, to ensure this is in accordance with national guidance.
• Ensure all necessary recruitment checks are in place including systems for assessing and monitoring risks, carrying out Disclosure and Barring Scheme (DBS) checks or risk assessment.
• Implement and improve a system of clinical audit cycles to ensure effective monitoring and assessment of the quality of the service.
• Ensure all staff have undertaken all mandatory training including infection control, health and safety, fire safety, mental capacity and equality and diversity. Ensure an induction pack is available for locum GPs.
• Ensure development areas identified during appraisals are followed up and monitored systematically.
• Ensure there are formal governance arrangements in place and staff are aware how these operate to ensure the delivery of safe and effective services. For example, infection control protocol, fire safety arrangements and legionella risk assessment.

In addition the practice should:

• Implement a system to promote the benefits of cervical screening and smoking cessation to increase patient uptake.
• Develop and implement a clear action plan, to improve the outcomes for learning disabilities patients and patients experiencing poor mental health.
• Ensure that within response to complaints patients are given the necessary information of the complainant’s right to escalate the complaint to the Ombudsman if dissatisfied with the response. The practice’s complaints policy should also be updated.
• Consider patient feedback regarding dissatisfaction with the sound quality of announcements in the waiting area.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice