Archived: Brownsover Medical Centre

We carried out an announced comprehensive inspection at Brownsover Medical Centre on 29 October 2019 and 30 October 2019 as part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for the population groups of older people, long-term conditions, families, young people and children, people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia). We rated the population group for working age people (including those recently retired and students) as requires improvement.

We rated the practice as requires improvement for providing safe services because:

• Staff recruitment practices were not consistently followed and there were shortfalls in the staff recruitment documents available in staff files.
• There was a lack of records to demonstrate that the provider had ensured that all staff were up to date with immunisations relevant to their role.
• There were some shortfalls in training not all non-clinical staff had completed chaperone training.
• We saw that PGDs were authorised and signed prior to the date they were signed by the practice nurses.
• We saw that the PSD for the flu vaccine were signed but did not contain information authorising the healthcare assistant to give the vaccine.
• There was no written criteria to demonstrate how alerts were prioritised and which alerts should be allocated to a clinician.
• The provider chaperone procedure did not provide staff with appropriate guidance on where they should position themselves when carrying out the role of a chaperone.

We rated the practice as good for providing effective, caring, responsive and well led services. We found that:

• The practice had clear systems to manage risks so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• Patients received care and treatment that met their needs. However, the practice uptake for childhood immunisations and cytology screening were below the national minimum uptake and the national targets.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• Services were tailored to meet the needs of individual patients. They were delivered in a flexible way that ensured choice and continuity of care.
• There were innovative approaches to providing integrated person-centred care.
• The practice had identified areas where there were gaps in provision locally and had taken steps to address them.

The areas where the provider must make improvements are:

• Care and treatment must be provided in a safe way for service users.
• Persons employed for the purposes of carrying on a regulated activity must be fit and proper persons.

The areas where the provider should make improvements are:

• Provide chaperone training for non-clinical staff.
• Review the chaperone procedure so that staff have clear guidance on where they should position themselves when carrying out the role of a chaperone.
• Continue to monitor and improve the uptake of childhood immunisations.

(Please see the specific details on action required at the end of this report).

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care