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Archived: GP at Hand Good Also known as Dr Jefferies & Partners, Lillie Road

Reports


Inspection carried out on 21 November 2017

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 21 April 2016 at Dr Jefferies & Partners, The Medical Centre, 139 Lillie Road (now re-named GP at Hand). The practice was rated as good for providing effective, caring, responsive and well led services and requires improvement for providing safe services. The overall rating for the practice was good. The full comprehensive report for the inspection on 21 April 2016 can be found by selecting the ‘all reports’ link for GP at Hand on our website at www.cqc.org.uk.

We undertook this announced focused inspection on 21 November 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 21 April 2016. This report covers our findings in relation to those requirements. The practice was not rated as part of this inspection.

Since the previous inspection on 21 April 2016 some adaptions had been made at the practice with a change of name, change to some GP managing partners and implementation of a new model of care with digital technology service provision. The digital element of service provision was not inspected as part of this focused inspection on 21 November 2017.

Our key findings were as follows;

The practice had addressed the concerns identified during the previous inspection and now complies with the regulation.

  • The practice had on site access to an automated external defibrillator (AED) to respond to a medical emergency.

  • A fire alarm system had been installed at the premises and additional fire safety arrangements had been implemented.

  • The patient waiting area had been refurbished including the replacement of fabric chairs with seating to address potential infection control risks.

We also reviewed the actions taken since the last inspection where we identified areas that the practice should make improvements.

Our findings were as follows;

  • A portable hearing loop had been installed to assist patients with hearing impairment.

The areas where the provider should make improvement are;

  • Arrange for non-clinical staff to undertake annual basic life support training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 21 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Jefferies & Partners, Lillie Road on 21 April 2016. Overall the practice is rated as good.

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.

  • Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. For example, all actions identified as part of a recent fire risk assessment had not been completed.

  • The practice had not risk assessed their decision not to provide a defibrillator as part of their medical emergency equipment.

  • The seating facilities in the practice waiting area required improvement.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

  • The majority of patients we spoke with said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment and all of the comment cards we received aligned with these views.

  • 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.

  • 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 provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure all recommendations made as a result of the fire risk assessment are completed and a fire alarm system is installed within the practice.

  • Ensure the availability of an automated external defibrillator (AED) or undertake a risk assessment if a decision is made to not have an AED on-site.

  • Ensure waiting area seating is clean and the scuffed and broken wooden panels under the seating and the tears in the fabric of the seating are addressed.

The areas where the provider should make improvement are:

  • Ensure all staff understand their responsibilities when acting as chaperones, including where to stand to be able to observe the examination.

  • Consider improving communication with patients who have a hearing impairment.

  • Advertise the interpreting service within the practice to inform patients this service was available to them.

  • Consider ways to actively identify carers and provide appropriate support for them.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice