Summerfield Primary Care Centre Also known as Dr Kulshrestha's Summerfield Family Practice

We carried out an announced comprehensive inspection at Summerfield Family Practice on 11 August 2016. The overall rating for the practice was Requires Improvement. The full comprehensive report on the August 2016 inspection can be found by selecting the “all reports” link for Summerfield family practice on our website at www.cqc.org.uk

This inspection was a comprehensive inspection carried out on 28th February 2018 to confirm that the practice had carried out their plan to meet legal requirements in relation to the breaches in regulations that we identified in our previous inspection in August 2016. This report covers our findings in relation to those requirements and also additional improvements identified. The practice is now rated as Requires Improvement overall.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Requires Improvement

Are services responsive? – Good

Are services well-led? – Inadequate.

At this inspection we found;

• The premises were clean and tidy and staff were aware of infection control procedures. However, the infection control audit completed by the practice was not effective as it did not assess or identify all areas where action was required.

• We looked at training records for staff and found that, in some areas, training appropriate to their role had not been completed. For example, some members of the clinical staff had not undertaken safeguarding vulnerable adults training, Mental Capacity Act training and immunisation updates.

• The national GP patient survey data was generally good; however responses relating to nursing services were less positive. The practice had not reviewed this feedback in order to identify areas for further improvement.

• Patients we spoke to on the day said they were generally happy with the practice and the staff, many of whom had been with the practice a long time

• The practice performance demonstrated that outcomes for patients were in line with CCG and national averages.

• Some of the governance arrangements within the practice were effective and supported the safe delivery of care. However there were areas where systems and processes lacked oversight in order to minimise risks to patients; for example, the monitoring of Patient Group Directions and the oversight of training.

• There was little evidence of effective systems around monitoring staff competencies.We saw examples of non-clinical staff updating clinical records on behalf of clinicians; however, there was no clinical oversight of this.

• The practice had addressed some but not all of the issues identified in the previous report and further issues had been identified around governance in this inspection.

• The practice did not have a system to make use of opportunites for learning from incidents and complaints such as failing to analysie the overall trends and develop actions plans around these.

• The practice did not make all reasonable adjustments to ensure access to vulnerable patients.

• Reported rates for cancer screening and childhood immunisations were low in comparison to local and national averages.

The areas where the provider MUST make improvements are:

• Ensure that care and treatment is provided in a safe way to patients.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider SHOULD make improvements are:

• Consider ways to further improve patient engagement in respect of immunisations and cervical cytology.

• Take a proactive approach to supporting carers, identified on the carers register.

• Ensure all staff are aware of the process for registering patients who are homeless.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice