- GP practice
Archived: The Avenue Medical Centre
All Inspections
6 July 2016
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
In December 2015 during a comprehensive inspection of The Avenue Medical Centre in Slough, Berkshire, we found concerns related to systems and processes which managed the safe and effective delivery of services. Following the inspection the provider sent us an action plan detailing how they would improve the areas of concern. The previous inspection in December 2015 had found three breaches of the regulations relating to the safe delivery of services, the need for consent and good governance.
We carried out a follow up inspection of The Avenue Medical Centre on 6 July 2016 to ensure these changes had been implemented and that the service was meeting the requirements of the regulations.
The ratings for the practice have been updated to reflect our findings following the improvements made since our last inspection in December 2015; the practice was now meeting the regulations that had previously been breached.
Specifically the practice was:
- Operating safe systems in relation to cleanliness and infection control. Risks to patients were assessed and well managed, this included completing actions following infection control and prescription security concerns we identified at the December 2015 inspection.
- The practice had revised arrangements to deal with emergencies and there was a systematic approach implemented to share national patient safety and medicines alerts with the full practice team.
- Appropriate arrangements were in place for recording written and verbal patient consent in line with legislation and guidance.
- Concerns identified at the December 2015 inspection regarding the management and monitoring of outcomes for patients with long term conditions and patients’ experiencing poor mental health had been addressed. The outcomes for these groups of patients had improved significantly.
The Avenue Medical Centre had taken full heed of the findings of the inspection undertaken in December 2015 and is now rated good for the provision of safe, effective, caring, responsive and well led services. All six population groups have also been re-rated following these improvements and are also rated as good.
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 of The Avenue Medical Centre on 17 December 2015. Overall the practice is rated as requires improvement.
Specifically, we found the practice to require improvement for provision of safe and effective services. It was good for providing caring, responsive and well led services. The concerns which led to these ratings apply to all population groups using the practice.
Our key findings across all the areas we inspected were as follows:
- Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
- Risks to patients and staff were assessed and well managed in some areas, with the exception of those relating to infection control, emergency procedures and prescription security. For example, the practice had not carried out any infection control audit or risk assessment and disposable curtains were not replaced regularly.
- Staff had received training appropriate to their roles and any further training needs had been identified and planned.
- We found that completed clinical audits cycles were driving positive outcomes for patients.
- Patients’ consent to care and treatment was not always sought in line with legislation and guidance.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
- The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group (PPG).
- Information about services and how to complain were available and easy to understand.
- The provider was aware of and complied with the requirements of the Duty of Candour.
- The practice had a limited governance system in place, was well organised and actively sought to learn from performance data, incidents and feedback.
The areas where the provider must make improvements are:
- Ensure there are formal governance arrangements in place and staff are aware how these operate to ensure the delivery of safe and effective services.
- Ensure infection control procedures and audits are fully implemented.
- Ensure consent is appropriately asked for and documented on all patient records.
- Review protocols and risks associated with the current arrangements for emergency procedures to ensure staff could access these if required.
- Ensure the process for the handling of blank prescription forms are handled in accordance with national guidance as these were not tracked through the practice and kept securely at all times.
- Ensure to develop and implement a protocol, to organise regular blood tests of patients on high risk medicines, for effective monitoring of side effects.
- Ensure to develop and implement clear action plans, to improve the outcomes for mental health and learning disabilities patients.
In addition the provider should:
- Review how patient safety alerts and other safety guidance are disseminated within the practice.
- Take action to review their approach and support for patients with carers responsibility.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice