Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection of Dr DJ Corlett & Partners at Beechfield Medical Centre, Spalding on 12 February 2015. Overall the practice is rated as requires improvement.
Specifically, we found the practice inadequate for providing safe services and requiring improvement for being effective and well led. It also required improvement for providing services for all the population groups. It was good for providing a caring and responsive service.
Our key findings across all the areas we inspected were as follows:
- There was not a clear system for reporting incidents, near misses or concerns, therefore evidence of learning and communication to staff was limited.
- Data showed patient outcomes were average or above for the locality. Although some audits had been started, we saw no evidence that audit cycles had been completed and therefore were not driving improvement in performance to improve patient outcomes.
- Patients said they were treated with compassion, dignity and respect. They were involved in their care and decisions about their treatment.
- Information about services and how to complain was available. Complaints had not always been investigated fully and therefore learning from them was limited.
- Urgent appointments were available on the day they were requested through the triage system.
- The majority of practice policies had been withdrawn for review as they were either out of date or inaccurate.
- The practice had not proactively sought feedback from staff or patients.
The areas where the provider must make improvements are:
- Ensure audits of practice are undertaken, including completed clinical audit cycles.
- Ensure there are mechanisms in place to seek feedback from staff and patients and this feedback is responded to.
- Ensure staff have appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
- Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision.
- Ensure there is a robust system to manage and learn from significant events, near misses and complaints.
Ensure staff are appropriately supported by means of training and appraisal.
- Have a system in place for monitoring and training of all staff.
In addition the provider should:
- Have a system in place to ensure that all staff receive and act accordingly on NPSA/MHRA alerts.
- Have a system in place to track prescription pads in the practice.
Where, as in this instance, a provider is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected no longer than six months after the initial rating is confirmed. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice