The Care Quality Commission
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Archived: Thatched House Medical Centre

Overall: Good read more about inspection ratings

136 High Road Leytonstone, London, E15 1UA (020) 8534 1671

Provided and run by:
Thatched House Medical Centre

All Inspections

28 April 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Thatched House Medical Centre on 22 June 2016. The overall rating for the practice was requires improvement. The full comprehensive report published in September 2016 Month can be found by selecting the ‘all reports’ link for Thatched House Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced follow up inspection on 28 April 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 22 June 2016. There were breaches in infection control and governance procedures. There were also concerns with the training of staff members, significant event processes, Quality Outcomes Framework exception reporting levels, there being no hearing loop in the premises and the lack of extended hours appointments. 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.

Our key findings were as follows:

• There was an up to date infection control audit and legionella risk assessment and the practice had carried out the actions identified as a result.

• Recruitment arrangements for newly appointed staff members followed national guidance; staff members had the appropriate checks including Disclosure and Barring Service checks carried out prior to employment.

• The practice had a clear vision and a strategy to deliver it; the vision was emailed to all staff members and displayed around the practice for staff and patients to see.

• All staff members had access to an online training portal and had completed all mandatory training and training relevant to their roles, this included chaperone training, fire training and infection control training. All staff had an appraisal documented in their record in the past 12 months.

• Significant events was standing agenda item at practice meetings, there were systems in place to analyse and identify themes from significant events and take appropriate action.

• The practice had disabled facilities including a hearing loop.

• The practice was a part of the local HUB which provided GP appointments to their patients on weekends and when the practice was closed, the GP also worked at the HUB and patients knew the days when she was on duty. There were telephone consultations each day at the end of GP sessions including in the evening.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

22 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Thatched House Medical Centre on 22 June 2016. Overall the practice is rated as requires improvements

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Some risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had received some training to provide them with the skills and knowledge, however we found this was limited and they had not received any training in infection control.
  • 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 was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Most patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. However some patients said they found it difficult to get through to the practice on occasions.
  • There was a leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on. However, the PPG did not meet regularly.
  • There was some governance arrangements, however there was no clear vision for the practice that staff were aware of.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Take action to address identified concerns with infection prevention and control practice such as, ensure all staff receive infection control training and undertake regular audits.
  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Develop a clear vision for the practice and a strategy to deliver it. Ensure it is shared with staff and ensure all staff knows their responsibilities in relation to it.

The areas where the provider should make improvement are:

  • Ensure all staff carrying out chaperone duties are trained to do so.
  • Implement systems to carry out a thorough analysis of the significant events to identify any themes and take appropriate action
  • The practice should review, with an aim to reducing their level of exception reporting in relation to Quality Outcome Framework (QOF).
  • Review the training made available to non –clinical staff to ensure they are trained appropriately for their role and ensure staff receive regular appraisals
  • Consider installing a hearing loop to improve communication with patients with a hearing impairment.
  • Consider offering extended appointments to enable working age patients more options to access the surgery outside of core opening hours.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice