- GP practice
Archived: Billet Lane Medical Practice
Important:
The provider of this service changed. See new profile
All Inspections
23 August 2017
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Billet Lane Medical Practice on 14 September 2016. The overall rating for the practice was requires improvement as safe, caring and well led were rated requires improvement and effective and responsive were rated as good. The full comprehensive report on the 14 September 2016 inspection can be found by selecting the 'all reports' link for Billet Lane Medical Practice on our website at www.cqc.org.uk.
This follow up inspection was undertaken as an announced comprehensive inspection on 23 August 2017. Overall the practice is now rated as Good.
Our key findings were as follows:
- Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
- Arrangements for managing medicines (obtaining, prescribing, recording, handling, storing, security and disposal) were safe; including systems for ensuring that medicines reviews and repeat authorisation functions were undertaken in accordance with recognised guidelines. In addition, the practice ensured that PGD’s (Patient Group Directions) were reviewed, signed and authorised for all locum nurses.
- The practice had reviewed storage arrangements for emergency medicines to allow staff to easily access them in an emergency.
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The practice had established a process for monitoring the use of prescription pads.
- Recruitment checks were now being undertaken for all locum clinicians.
- Staff appraisals had taken place to ensure staff had the appropriate skills and training to do their jobs. Learning and development needs were being identified, planned and supported.
- Feedback from patients about their care was consistently positive.
- Carers were being identified and recorded to enable carers to receive appropriate support.
- The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs.
- The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. For example, the practice website had been developed to help share information about the practice and the services it provides.
- The practice had good facilities and was well equipped to treat patients and meet their needs.
- The practice actively reviewed complaints and how they are managed and responded to, and made improvements as a result.
- The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.
- The practice had strong and visible clinical and managerial leadership and governance arrangements. For example, policies and procedures and business continuity arrangements were up to date and in line with practice arrangements and published best practice guidelines.
However, there were also areas of practice where the provider should make improvements.
The provider should:
- Review their fire safety policy to ensure Fire wardens are identified andappropriately trained.
- Continue to review access to the practice via telephone so that patients can make timely appointments and arrange to speak to a GP or nurse.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
14 September 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Billet Lane Medical Centre on 14 September 2016. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
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When things went wrong, reviews and investigations were not sufficiently thorough and necessary improvements were not always made.
- Risks to patients were assessed and well managed with the exception of those relating to arrangements for managing high risk medicines.
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Governance arrangements did not always operate effectively. For example, the surgery had a number of policies and procedures to govern activity, but some were overdue a review.
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Arrangements to support carers did not always operate effectively.
- Information about services and how to complain was available and easy to understand. However, it was not clear how improvements were made to the quality of care as a result of complaints and concerns.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
- Patients said they were treated with compassion, dignity and respect and but they were involved in their care and decisions about their treatment.
- Some patients said they found it difficult to make an appointment at times and this was reflected in the patient survery results. However, patients were able to access their names GP and there was continuity of care. Urgent appointments were available the same day.
- There was a clear leadership structure and staff felt supported by management. The practice had begun to seek feedback from staff and patients but processes had not been fully established.
- 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 that arrangements for managing medicines (obtaining, prescribing, recording, handling, storing, security and disposal) are safe; including systems for ensuring that medicinesreviews and repeat authorisation functions are undertaken in accordance with recognised guidelines. In addition, ensure that PGD’s (Patient Group Directions) are reviewed, signed and authorised for all locum nurses.
- Ensure all recruitment checks are undertaken for all locum clinicians.
- Ensure that carers are identified and recorded to enable carers to receive appropriate support.
- Ensure policies and procedures and business continuity arrangements are up to date and in line with practice arrangements and published best practice guidelines
The areas where the provider should make improvement are:
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Provide fire wardens with up to date fire warden training.
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Review storage arrangements for emergency medicines to allow staff to easily access them in an emergency.
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Ensure that a process is in place for monitoring the use of prescription pads.
- Consider reviewing how complaints are analysed in the practice to support continuous practice improvement.
- Progress plans to appraise all non clinical staff of their performance to ensure they are appropriately skilled and trained and that their learning and development needs are identified, planned and supported.
- Review arrangements in regard to patient participation to ensure that they support the improvement of quality and delivery of services.
- Continue to progress plans to develop a practice website to help share information about the practice and the services it provides.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice