Archived: Town Hall Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Town Hall Surgery on 02 March 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.

• Risks to patients were assessed and well managed, however policies and procedures for staff were either out of date or not in place including those related to safeguarding, health and safety and recruitment.

• The practice did not follow safe recruitment practices when employing new staff in line with legal requirements.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance.
• Data showed patient outcomes were in line with or above those locally and nationally.

• Feedback from patients about their care was consistently and strongly positive.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a result of feedback from patients.

• Information about services and how to complain was available and easy to understand.

• Patients said they found it easy to make an appointment and that there was continuity of care, with urgent appointments available the same day.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• There was a clear leadership structure and staff felt supported by management, however staff did not have access to a formalised programme of training and professional development. The practice proactively sought feedback from staff and patients, which it acted on.

The areas where the provider must make improvements are:

• Ensure recruitment policies and procedures are in place and arrangements include all necessary employment checks for all staff.
• Patients were at potential risk of harm because systems and processes were not in place for, recruitment, health and safety and infection control.
• There was insufficient attention to safeguarding. Staff were aware of their responsibilities to report concerns however; there was no policy or procedure in place for staff to follow. A lead was in place but not all staff had received training and evidence of GPs being trained to level 3 was not available.
• Ensure staff have access to a formal programme of training and professional development and a record of training carried out is maintained.

In addition the provider should:

• Ensure staff appraisals are undertaken
• Ensure a formal risk assessment or rationale for the emergency medication is carried out.

• Ensure all complaint letters include details of how to appeal and referral details to external bodies.
• Carry out clinical audits and re-audits to improve patient outcomes.
• Ensure a robust infection control system is implemented including audits.

• Ensure practice meetings are minuted.

• Ensure a Business Continuity Plan is in place.

Where a practice is rated as inadequate for one of the five key questions or one of the six population groups the practice will be re-inspected within six months after the report is published. If, after re-inspection, the practice has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place the practice into special measures. Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice