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Littlebury Medical Centre Good


Review carried out on 21 February 2020

During an annual regulatory review

We reviewed the information available to us about Littlebury Medical Centre on 21 February 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

During a routine inspection

Littlebury Medical Centre had been inspected previously on the following dates: -

  • 5 April 2018 under the comprehensive inspection programmed. The practice was rated as Requires Improvement overall. Breaches of legal requirements were found in relation to safe care and treatment, safeguarding service users from abuse and improper treatment and governance arrangements within the practice. Requirement notices were issues which required them to submit an action plan on how they were going to take action to meet these requirements.

We carried out an announced comprehensive inspection at Littlebury Medical Centre on 6 February 2019 as part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as good overall.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The practice did not always have clear and effective processes for managing risk.
  • The practice did not always act on appropriate and accurate information.

Whilst we found no breaches of regulations, the provider should:

  • Review and embed the current systems for the recording of near misses in the dispensary, management of legionella, fire safety and emergency equipment and medicines.
  • Continue the plan to drive improvement through clinical audit and the monitoring of national patient survey data to improve the experience of patients.
  • Put a plan in place to ensure the nursing team have regular meetings which are documented.
  • Improve the identification of carers to enable this group of patients to access the care and support they need and ensure information is available in line with NHS England Accessible Information Standard.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection carried out on 5 April 2018

During a routine inspection

This practice is rated requires improvement overall. (Previous inspection December 2014 was Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

We carried out an announced inspection at Littlebury Medical Centre on 5 April 2018 as part of our inspection programme.

At this inspection we found:

  • There was a system in place for reporting and recording significant events.
  • Patients were at risk of harm because some systems and processes in place were not effective to keep them safe. For example, patient safety alerts, monitoring of the cold chain, checking of emergency medicines and equipment, sepsis awareness.
  • Some of the systems, processes and practices in place to keep people safe and safeguarded from abuse were not effective.
  • There were some arrangements for identifying, recording and managing risks but not all had been well managed. For example, fire safety and legionella.
  • Most of the medicines management practices in place kept patients safe.
  • We saw limited evidence of quality improvement to improve patient outcomes.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Comments cards we reviewed told us that patients said they were treated with compassion, dignity and respect. They felt cared for, supported and listened to.
  • Urgent appointments were available on the day they were requested through the triage system.
  • The July 2017 national patient survey results had been reviewed but not all had actions in place to improve the areas of concerns identified by the patients registered at the practice.
  • There was no overarching governance framework in place to support the delivery of the strategy and good quality care.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences.
  • Ensure patients are protected from abuse and improper treatment.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:-

  • Ensure that all staff have had an appraisal in the last 12 months
  • Continue to monitor the system in place for prescriptions to ensure they are signed before the medicines are dispensed.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection carried out on 4 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Littlebury Medical Centre on 4 December 2014.

Overall the practice is rated as good.

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

  • Urgent appointments were available the same day.
  • The practice had good facilities including disabled access and was found to be clean and tidy.
  • Information about services and how to complain was available.
  • Patients said they felt the practice offered an excellent service and staff were friendly and caring and treated them with dignity and respect
  • There were systems in place to reduce risks to patient safety for example, infection control procedures.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Staff had received training appropriate to their roles.
  • Recruitment checks were carried out and the appropriate recruitment checks had been undertaken prior to employment.
  • The practice had a comprehensive business continuity plan in place for major incidents such as power failure or building damage.
  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice