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Archived: Family Health Care Good Also known as Lydia House Surgery


Inspection carried out on 12 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This inspection of Family Health Care practice was carried out on 12 July 2017 and was to check improvements had been made since our previous inspection on 5 May 2016. Following our May 2016 inspection the practice was rated as requires improvement overall. Specifically they were rated as requires improvement for safe, effective, responsive and well led and good for caring. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for Family Health Care on our website at

As a result of our findings at this inspection we took regulatory action against the provider and issued them with requirement notices for improvement.

Following the previous inspection on 5 May 2016 the practice sent us an action plan that explained what actions they would take to meet the regulations in relation to the breaches of regulations.

At this inspection we found that the majority of the improvements had been made and progress had been made across all areas of concern. Overall the practice is now rated as good.

Our key findings were as follows:

  • Significant events were fully investigated; patients received support, honest explanations and apologies. The learning was shared with appropriate staff.
  • Staff demonstrated that they understood their responsibilities and all had received training on safeguarding children and vulnerable adults relevant to their role.
  • Staff received appropriate training to fulfil their roles.
  • There was a clear recruitment process in place for permanent and locum staff, however some staff files did not contain evidence of photographic identify checks. Clinical staff files contained evidence of vaccination and level of immunity against Hepatitis B.
  • There were systems in place to ensure safe medicines management including the monitoring of fridges to ensure medicines were stored at the correct temperatures.
  • Patients prescribed high risk medicines received appropriate review.
  • The practice had a system in place to deal with any medicines alerts although this could be strengthened by maintaining an audit trail of action taken.
  • Infection control audits were completed and action taken to resolve any issues.
  • The practice had installed a new fire alarm which complied with recommendations from a fire risk assessment.
  • A Legionella risk assessment had been completed. The practice monitored temperatures however had not followed up on other recommendations from the risk assessment. Following our inspection they took action to rectify this.
  • Policies and procedures were up to date, practice specific and staff were aware of where to find them and their contents.
  • Feedback from patients about their care was consistently positive.
  • One two cycle clinical audit had been completed since our last inspection. The practice had recently employed a pharmacist and reviewed their staffing structure to allow for more quality improvement activity to take place.
  • The practice had a system for identifying and supporting the carers on their register.
  • The complaints policy was clearly visible to patients. Complaints were fully investigated and there was a clear audit trail of actions taken by the practice. Informal complaints were not being analysed for themes and trends.
  • There were processes in place to gather and act on patient feedback including a patient participation group (PPG).
  • Staff had worked as a team to act on the feedback from the previous inspection.

However, there were still areas of practice where the provider needed to make improvements.

The provider should:

  • Implement a system for evidencing action taken to respond to medicine alerts.
  • Continue to increase quality monitoring and improvement activity through audits and other reviews.
  • Make an action plan for dealing with the recommendations from the Legionella report and identify a person to be responsible for actions with deadlines for action.
  • Consider how to encourage attendance for breast screening.
  • Consider keeping a log of informal complaints for trends analysis and audit trail.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 05 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Family Health Care on 5 May 2016. Overall the practice is rated as requires improvement. The practice was rated as requires improvement for the safe, effective, responsive and well led domains and rated as good for the caring domain.

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

  • The practice investigated safety concerns when things went wrong. However learning from these incidents was not always recognised, shared or acted on to minimise recurrences.
  • The practice had policies and procedures in place to safeguard vulnerable children. However some staff had not undertaken training in safeguarding vulnerable adults and no staff had undertaken safeguarding adults training.
  • All staff that carried out chaperone duties had appropriate checks in place including Disclosure and Barring Services (DBS) checks. However not all staff who carried out these duties had undertaken training.
  • Infection control procedures were being followed. Regular infection control audits were being carried out. However some staff had not undertaken infection control training. There was no legionella risk assessment in place. There was no evidence that all relevant staff had Hepatitis B vaccinations / immunity.
  • All equipment was routinely checked, serviced and calibrated in line with the manufacturer’s instructions. However the practice could not demonstrate that the vaccine fridge temperatures were accurate.
  • There were risk assessments in place for areas including fire safety, infection control, health and safety, premises and equipment. However there was no fire alarm system and not all staff had undertaken fire safety training.
  • There was a detailed business continuity plan in place to deal with any untoward incidents which may disrupt the running of the practice.
  • The practice had an effective recruitment procedure. Newly employed staff undertook a period of role specific induction.
  • Medicines were stored securely and there were systems in place to check they were in date and available in sufficient quantities. However emergency medicines and equipment were stored in various areas throughout the practice and some staff were unsure as to their whereabouts.
  • Clinical audits were not carried out routinely to monitor and improve outcomes for patients.

  • Some patients did not have regular medicines reviews where they were prescribed medicines on a long term basis or where they were prescribed high risk medicines.

  • Patients consent to care and treatment was sought in line with current legislation and guidance.

  • Patients were treated with dignity and respect and those spoken with were happy with the care and treatment they received.

  • The practice identified where patients that were carers and offered them appropriate support.

  • Same day urgent appointments or telephone consultations and home visits were available. Patients spoken with told us they were satisfied with the appointment system. .
  • The practice did not offer extended hours such as early morning or late evening appointments. These were available at their other Surgery but this was not widely advertised.
  • Complaints were investigated and responded to appropriately and apologies given where relevant. Information about the complaints system was not readily available for patients to access.
  • The practice had suitable facilities and equipment to treat patients and meet their needs.
  • There was a leadership structure and staff felt supported by management. However some of the policies and procedures in place were not practice specific.
  • The practice did not have a patient participation group to help gain patients comments and views as to how the practice is managed.

There were areas of practice where the provider needs to make improvements.

Importantly the provider must:

  • Ensure that risks to patients and staff are assessed and managed. This relates to assessing the need for a fire alarm system, assessing risks in relation to legionella and ensuring that medicines which require refrigeration are stored at the appropriate temperatures.

  • Ensure that patients receive regular reviews of their medicines, including those that are high risk.

  • Ensure that staff receive training in to meet the needs of patients and to keep them safe. This includes training in safeguarding vulnerable adults and children, chaperone training, fire safety and infection control training.

  • Ensure that the quality of the services provided is monitored through clinical and other reviews and audits.

Additionally the should:

  • Review the arrangements for recording how significant events are investigated and how learning arising from these is used to make improvements and minimise recurrence.

  • Review the arrangements for the storage of emergency medicines and equipment to facilitate ease of access in the event of a medical emergency.

  • Review staff records so that they include evidence that staff have been vaccinated / have immunity against Hepatitis B.

  • Update information that is provided to patients so that it information about the practice complaints procedure and arrangements for accessing services when the practice is shut.

  • Review the practice policies and procedures so that they are practice bespoke and relevant to the day to day management of the practice.

  • Consider the implementation of a patient’s participation group.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice