Archived: The Practice Beaumont Leys

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Practice Beaumont Leys on 16 August 2016. Overall the practice is rated as good.

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

• There was a system in place for reporting and recording significant events and lessons were shared to make sure action was taken to improve safety in the practice.

• Not all staff reported significant events as required.

• There was no system in place to monitor the use of blank prescription forms and pads.

• The correct authorisation process was not always followed to allow nursing staff to administer vaccines under a patient group directive.

• The temperature of the room where emergency medicines were stored was not monitored and the temperature for one of the vaccine fridges was not always documented in line with the practice protocol.

• Not all areas of the practice were maintained and cleaned appropriately to prevent the spread of infection.

• Exception reporting data was higher than the national average in some areas, however the practice were able to demonstrate errors in this data.

• The practice carried out clinical audits to demonstrate quality improvement.

• The locum induction schedule was not always followed.

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

• We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

• Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff.

• The practice had a clear vision and objectives to deliver quality care and promote good outcomes for patients.

• There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity.

• There was an overarching governance framework which supported the delivery of the strategy and quality care.

• The minutes of the practice meetings were limited and did not show that previous agenda items or actions from previous meetings were followed up.

The areas where the provider must make improvement are:

• Ensure there is a system in place to monitor the use of blank prescription forms and pads.

• Ensure the correct authorisation process is followed to allow nursing staff to administer vaccines under a patient group directive.

• Ensure all areas of the practice are maintained and cleaned to prevent the spread of infection.

The areas where the provider should make improvement are:

• Consider the significant events reported and encourage all staff to report as such.

• Record the room temperature where emergency medicines are stored and document fridge temperatures in line with the practice protocol.

• Review national data available pertinent to the practice to enable developments in patient services, specifically exception reporting data.

• To review the locum induction and ensure the protocol is followed.

• Document discussions and review previous agenda items that had actions against them during practice meetings.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice