Archived: Ravenscroft Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Ravenscroft Medical Centre on 14 July and 19 July 2016. Overall the practice is rated as requires improvement.

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

• Significant event reviews and investigations were not always sufficiently thorough. For example, there was limited evidence that meetings took place to share learning from significant events and take steps to maintain or improve patient safety.

• We identified concerns with the arrangements for storing vaccines in that the practice could not provide fridge temperature records prior to November 2015. Given our concerns, we notified Public Health England of our findings.  Shortly thereafter, we were advised that no further action was required.

• Governance arrangements did not always operate effectively. For example, there was limited evidence that staff routinely met to identify, monitor and take mitigating actions against risks.

• Clinical audits were being used to drive improvements to patient outcomes.

• Data showed that with the exception of cervical screening uptake, most patient outcomes were above the national average.

• Data from the national GP patient survey showed patients rated the practice higher than others on most aspects of care.

• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

The areas where the provider must make improvements are:

• Ensure that cervical screening uptake is monitored and action taken as necessary to improve performance.
• Ensure that the vaccines fridge temperatures are being regularly monitored to ensure the vaccine’s effectiveness.
• Ensure that a risk assessment is undertaken of its decision not to keep a defibrillator on the premises.
• Ensure that control of substances hazardous to health risk assessments take place.
• Ensure that annual fire risk assessments take place.
• Ensure that there are systems in place to assess, monitor and mitigate risks relating to the health, safety and welfare of service users (for example, to ensure annual calibration of clinical equipment).

In addition the provider should:

• Investigate safety incidents thoroughly, including ensuring that staff learning is shared and documented at clinical meetings and that this involves all relevant people.

• Review systems in place for identifying and supporting carers.

Please note that Quality and Outcomes Framework (QOF) data referred to in this report relates to unverified data provided by the practice on the day of our inspection. QOF is a system intended to improve the quality of general practice and reward good practice.

Ravenscroft Medical Centre also operates a branch location which is open three hours per day for approximately thirty nine weeks per year. Patient registration is restricted to students of Middlesex University.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice