- GP practice
Crown Medical Centre
All Inspections
7 April 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection of this practice on 17 December 2015. During this inspection an overall rating of good was made, with the effective, caring, responsive and well led areas all being rating as good. However, a breach of Regulation 12 of The Health and Social Care Act (Regulated Activities) Act 2014 was found. This related to the safe delivery of services.
The practice required improvement for the provision of safe services to ensure all Patient Group Directions and Patient Specific Directions are appropriately authorised before vaccines were administered to patients. In addition we also recommended the practice should consider improvements in some other areas to improve the safe delivery of services.
After the comprehensive inspection, the practice sent us their action plan and recorded within this what they would do to meet legal requirements in relation to the Regulation 12 breach.
We undertook a desk-based focused inspection on 07 April 2016 to check that the practice had followed their action plan and to confirm that they now met legal requirements. We did not visit the practice.
We found the practice was meeting the regulation that had previously been breached in relation to safe care and treatment. The practice provided evidence to us that Patient Group Directions and Patient Specific Directions were authorised and signed by the authorising clinicians before vaccines were administered to patients.
During our previous inspection we recommended the practice should consider additional improvement and these had been improved as follows:
- The recruitment policy had been reviewed so relevant checks are now carried out and this was now recorded in staff records.
- The contract arrangements with the cleaning contractor had been reviewed and action taken, including increasing cleaning hours and more thorough cleaning.
- The complaint procedure had been amended so all patients received a satisfactory response, to both verbal and written concerns, in line with good practice.
- Governance arrangements had been reviewed and lead roles confirmed to ensure all checks, audits, complaints, significant events, policies and day to day management of the practice were carried out, reviewed and the information from these informed improvements in service quality and staff development.
- The clinical leadership of the nursing team had been reviewed and a GP confirmed to the staff as clinical lead. Their role was to provide support and guidance on clinical issues.
We have amended the rating for this practice to reflect these changes. The practice is now rated as good for the provision of safe services.
This report only covers our findings in relation to these requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Crown Medical Centre on our website at www.cqc.org.uk.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
17 December 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Crown Medical Centre on 17 December 2015. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
- There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
- Risks to patients were generally well managed and assessed, however, risks to patients in regard of the management of vaccinations were not sufficiently robust.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
- Information about services and how to complain was available and easy to understand.
- Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
- The practice had good facilities and was well equipped to treat patients and meet their needs.
- 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 provider was aware of and complied with the requirements of the Duty of Candour.
The area where the provider must make improvement is:
- Ensuring all Patient Group Directions and Patient Specific Directions are authorised and signed before vaccinations are provided to patients.
The areas where the provider should make improvement are:
- Review recruitment processes to ensure checks such as vaccination status are evidenced clearly in staff records.
- Review contract arrangements with the cleaning contractor.
- Review how complaints are recorded to assist improved governance.
- Review governance arrangements and identify a lead person to ensure all checks, audits, complaints, significant events, policies and day to day management of the practice are carried out, reviewed and used to inform improvements in service quality and staff development.
- Review the clinical leadership of the nursing team, to provide support and guidance on clinical issues
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice