Archived: Tile Cross Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Tile Cross Surgery on 5 May 2016. Overall the practice is rated as requires improvement. There are two surgery locations that form the practice; these consist of the main practice at Church Road and the branch practice at Tile Cross Surgery. Systems and processes are shared across both sites. During the inspection we visited both locations. As the locations have separate CQC registrations we have produced two reports. However where systems and data reflect both practices the reports will contain the same information.

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

• The practice had defined and embedded systems in place to keep people safeguarded from abuse. There was a system in place for reporting and recording significant events and staff we spoke with were aware of their responsibilities to raise and report concerns, incidents and near misses.
• We observed the premises to be clean and tidy, but the building was situated in a residential area which posed difficulties for parking and access.
• The practice had reviewed its fire evacuation procedures with the local fire officer to ensure that robust systems were in place.
• Clinical audits were carried out to demonstrate quality improvement and to improve patient care and treatment and results were circulated and discussed in the practice.
• 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. Some staff had not received regular appraisals.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• There was limited information on display about local services and no details of carers groups or support organisations were available.
• Information about how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Due to resignation of four GP Partners, the practice had employed locums to ensure that appointments were available daily.
• There was a clear leadership structure and staff felt supported by management.
• The provider was aware of and complied with the requirements of the duty of candour.
• Governance and risk management arrangements were in place, but were not operating effectively and therefore the provider did not have appropriate oversight of risk. For example no risk assessments had been completed in the absence of disclosure and barring checks (DBS) for members of the reception team who occasionally chaperoned.
• Areas of poor performance in relation to QOF and screening had been considered with action plans in place to mitigate this.
•  Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs. We saw evidence that quarterly multidisciplinary team meetings took place.

The areas where the provider must make improvements are:

The provider did not have effective systems to enable them to identify, assess and mitigate risks by;

• Seeking and acting on feedback received to demonstrate improvements to services.

• Keeping records to demonstrate that staff were up to date with the immunisations recommended for staff who are working in general practice, such as Hepatitis B, mumps and rubella (MMR) vaccines.

• Ensuring all staff are risk assessed in the absence of a Disclosure and Barring Service (DBS) check when carrying out chaperoning duties.

Patients were not protected against the risks associated with receiving unsafe care or treatment in that;

• Patient Specific Directions were not in place for patients who received vaccinations by the Health Care Assistant.

The areas where the provider should make improvement are:

• Ensure staff who chaperone are aware of and comply with recommended chaperoning guidelines when observing treatments and examinations.

• Have information available for patients on support groups and services available in the local area.

• Review current processes for ensuring patients with a learning disability receive annual health checks.

• Ensure that staff are informed and involved in the overall vision of the practice.

• Complete appraisals for all staff including development plans.

• Monitor quality and outcome framework (QOF) indicators to ensure patient reviews are up to date and completed.

• Continue to review the registers for patients with long term conditions and mental health needs to ensure appropriate reviews are in place.

• Consider how to proactively identify and support carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice