Archived: Islip Manor Medical Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Islip Manor Medical Centre on 8 March 2016. Overall the practice is rated as requires improvement.

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

• Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, documentation of significant events was not thorough and did not include evidence of shared learning.
• Risks to patients were assessed and managed, with the exception of those relating to medicines management, health and safety and management of medical emergencies.
• Data showed patient outcomes were low compared to the national average. Although some CCG led audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.
• Patients said they felt the practice offered an excellent service and staff were helpful, caring, friendly, considerate and treated them with dignity and respect.
• The practice did not have good facilities and was in need of refurbishment.
• 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.
• The practice did not have an effective system in place to manage and learn from complaints received.
• The practice had policies and procedures to govern activity, but some of these required review.

The areas where the provider must make improvement are:

• Ensure that the processes for monitoring fridge temperatures are followed in line with national guidance.
• Ensure that risks are effectively assessed, monitored and mitigated across all areas of the practice. Including those for health & safety and not having an automated external (AED) defibrillator for use in a medical emergency.
• Ensure that the need for DBS checks are risk assessed, or DBS checks are completed for all staff required to undertake chaperone duties.
• Implement a system to ensure all locum clinical staff are kept up to date with national guidance and guidelines.
• Ensure an effective system for the recording, management, review and shared learning of all complaints received including those raised verbally.
• Implement a programme of clinical audit including re-audit to demonstrate quality and improvement.

The areas where the provider should make improvement are:

• Improve the process for recording significant events including documentation clarity of shared learning and outcomes.
• Improve the systems in place for the management of blank prescription forms to ensure they meet recommended guidance.
• Ensure clinical staff completes Mental Capacity Act (MCA) training.
• Advertise within the practice the provision of the translation service for patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice