Archived: Crosland Moor Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Crosland Moor Surgery on 29 June 2016. Overall the practice is rated as requires improvement.

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. However, learning from incidents was shared informally and not embedded into updated policies and procedures.
• Risks to patients were mostly assessed and well managed. However, not all recruitment checks were consistently completed and the provider had not undertaken a recent fire drill.
• 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.
• 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 on request and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and 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.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

The provider must make improvements in order to operative effective governance systems. This includes improving records of meetings within the practice and embedding learning from significant events into revised polcies and procedures. They must also develop, and operate effectively, systems to monitor staff training, the scheduling and completion of fire drills, records of cleaning and be able to demonstrate quality improvement activity, including clinical audits.

In addition the provider should:

• Review the current fire safety procedures.
• Review their recruitment arrangements to assure themselves that all necessary employment checks are completed for all staff prior to them commencing employment with the practice.
• Review the provision of information about the complaints procedure in reception.
• Review working arrangements across the clinical team to facilitate the provision of practice protected time and attendance at internal governance meetings is enabled for all relevant staff.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice