Archived: Brixton Water Lane Practice

We carried out an announced comprehensive inspection at Brixton Water Lane Surgery on 28 April 2016. Overall the practice is rated as requires improvement.

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

• There was an inconsistent approach to the reporting and management of significant events with some staff not being aware of the practice’s significant event procedure and others not being included in learning from events. We found evidence that not all significant events were managed under the practice’s process.

• Risks to patients in respect of infection control, fire safety, recruitment and staffing and response to emergencies were inadequately assessed and managed.
• In the majority of respects staff assessed patients’ needs and delivered care in line with current evidence based guidance and had the skills, knowledge and experience to deliver effective care and treatment. However we saw several examples where assessments were either not undertaken or not compliant with current legislation and guidance around capacity and consent.
• 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.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• The practice was not easily accessible or ideally suited to patients with mobility problems, young children or those with hearing impairment. There had been no assessment undertaken of the suitability of the premises for these patients.
• Although there was a leadership structure in place some staff were uncertain of who acted as leaders in certain areas.
• Practice policies were not always tailored to practice requirements and some contained out of date or insufficient information.
• Staff told us they felt supported by management. The practice acted on feedback provided by staff.
• The practice did not offer online appointments.
• The practice did not have a functioning Patient Participation Group and we saw no evidence of the practice obtaining feedback from their patient population.
• The provider was aware of the Duty of Candour though we only saw the practice disclose information to patients when they complained. The practice was unable to provide any example of a patient safety alert that it had acted on.

The areas where the provider must make improvement are:

• Ensure that consent and capacity is assessed and the outcome of any assessment documented in accordance with legislation and guidance.

• Ensure that there are adequate systems in place for the receipt, distribution and management of relevant patient safety alerts and for reporting and managing significant events and that appropriate action is taken including notifying patients who may be affected. Ensure that all policies and procedures meet the requirements of the practice and contain all required contemporaneous information. Ensure annual infection control audits, legionella risk assessment, regular fire risk assessments and a risk assessment for staff whose DBS certificates have expired are carried out and that risks identified are addressed. Ensure that all prescriptions are stored securely and there is a system in place for monitoring their use.

• Ensure that appropriate pre-employment checks are completed and that professional registrations are periodically monitored.

• Ensure that all staff have received mandatory training including safeguarding and fire safety.

The areas where the provider should make improvement are:

• Review staffing levels and ensure that there are always sufficient numbers of staff on the premises to adequately meet patient need.

• Continue to monitor the arrangements in place to deal with emergencies and major incidents including always having a full stock of emergency medicines on the premises and a business continuity plan which is up to date and comprehensive

• Continue to improve identification and management of patients with long term conditions.

• Ensure that quality improvement initiatives including audits clearly demonstrate learning and improvement.

• Consider how to involve all staff in regular meetings and ensure that key issues, actions and learning are recorded and shared.

• Ensure all clinical staff complete Mental Capacity Act training.

• Review the accessibility of the premises and opportunities to make reasonable adjustments particularly for those with reduced mobility and those with young children.

• Advertise the available translation services in the waiting area.

• Offer online appointments.

• Put a clear documented leadership structure in place and ensure that all staff are aware of this.

• Engage with the practice’s patient population and use feedback in the practice’s decision making process related to service provision.

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