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Inspection Summary


Overall summary & rating

Good

Updated 7 December 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Taverham Partnership on 12 April 2017. The overall rating for the practice was requires improvement, with requires improvement for providing safe, caring and well led services. The practice was rated as good for providing effective and responsive services. The full comprehensive report on the 12 April 2017 inspection can be found by selecting the ‘all reports’ link for the Taverham Partnership on our website at www.cqc.org.uk.

We undertook a focussed follow up inspection on 16 November 2017 to check they had followed their action plan and to confirm they now met legal requirements in relation to the breaches identified in our previous inspection on 12 April 2017. This report only covers our findings in relation to those requirements.

Overall the practice is now rated as good overall, and good for providing safe, caring and well led services.

Our key findings from this inspection were as follows:

  • There was a fire risk assessment and action plan in place.

  • The system for reporting, recording and learning from significant events had improved.

  • There was an infection prevention and control audit in place with associated action plan. The lead was trained for the role.

  • Staff had been provided with a forum for feedback and management were taking actions on identified issues. There was evidence of improved governance arrangements.

  • The standard operating procedures for the dispensary were detailed enough to assure safety.

  • Improvements had been made to the overall patient satisfaction outcomes on the GP patient survey, published in July 2017. The practice had recorded 75 patients as carers (approximately 0.7% of the practice list) and had thoroughly reviewed the system for identifying and offering carers support.

  • Electrical equipment was calibrated and tested appropriately.

  • The system for identifying patients and the coding of their medical records, particularly those with diabetes, had been reviewed. The staff were now using a system for the scanning and coding of letters to ensure patients records were coded correctly. The GPs were aware that poor coding was identified at our previous inspection. They had reviewed the patients with diabetes to ensure those- patients with diabetes that had been expected had been coded correctly.

  • The system for managing complaints had been improved. The practice monitored and recorded verbal complaints in order to identify any trends. The practice shared learning from complaints at meetings and we saw minutes of meetings to confirm this. The practice had a system in place to ensure the closure of complaints.

  • There was a child oxygen mask available in the emergency equipment.

The areas where the provider should make improvement are:

  • Continue to identify and offer support to carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 7 December 2017

Our focused inspection on 16 November 2017 found that:

  • There was a fire risk assessment and action plan in place. This had been completed by an external company and was comprehensive.

  • The system for reporting, recording and learning from significant events had improved. They were recorded on a log which gave the management team oversight and enabled trend analysis. Significant events were discussed in meetings and we saw evidence of this.

  • There was an infection prevention and control audit in place with associated action plan. The lead was trained for the role. The practice had reviewed the cleaning schedules and had employed a new cleaning company.

  • The standard operating procedures for the dispensary were detailed enough to assure safety.

  • Electrical equipment was calibrated and tested appropriately in April 2017.

  • There was a child oxygen mask in the emergency equipment and an oxygen sign on the door where oxygen was stored.

Effective

Good

Updated 6 June 2017

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes for most clinical indicators was comparable to or above the Clinical Commissioning Group (CCG) and England averages. Where practice performance was below average, we were told there was an issue with read coding hospital correspondence.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

  • Clinical audits demonstrated quality improvement.

  • Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • There was evidence of appraisals and personal development plans for all staff.

Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 7 December 2017

Our focused inspection on 16 November 2017 found that:

  • The practice had identified 75 patients as carers (approximately 0.7% of the practice list). The practice had thoroughly reviewed the patients on the list to ensure they were appropriate and had sent letters to them to offer flu vaccinations and to signpost them to local support groups.

  • Improvements had been made to the overall patient satisfaction outcomes on the GP patient survey, published in July 2017. The practice was now rated as above or in line with local and national averages for several aspects of care.

Responsive

Good

Updated 6 June 2017

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.

  • The majority of patients we received comments from and spoke with said they did not find it easy to make an appointment with a named GP, but could get appointments with other GPs or a nurse. Urgent appointments were available the same day.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • Information about how to complain was available but not displayed in the waiting room. Evidence demonstrated the practice responded quickly to issues raised. Learning from complaints was shared with staff. Verbal, informal complaints were not recorded.

Well-led

Good

Updated 7 December 2017

Our focused inspection on 16 November 2017 found that:

  • Staff had completed an anonymised survey relating to management. The management team were exempt from this and uptake for the survey was 100%. Actions from this survey had been completed including 360 degree feedback for all managers and focus groups to discuss the outcomes of the survey and develop solutions. Staff spoken to on the day of inspection reported they felt management had been open and honest with feedback and communication.

  • Governance arrangements at the practice had improved. The management team had good oversight and management of risks, including those relating to infection control and fire.
Checks on specific services

Older people

Good

Updated 7 December 2017

The provider had resolved the concerns for providing safe, caring and well-led services identified at our inspection on 12 April 2017, which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People with long term conditions

Good

Updated 7 December 2017

The provider had resolved the concerns for providing safe, caring and well-led services identified at our inspection on 12 April 2017, which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Families, children and young people

Good

Updated 7 December 2017

The provider had resolved the concerns for providing safe, caring and well-led services identified at our inspection on 12 April 2017, which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Working age people (including those recently retired and students)

Good

Updated 7 December 2017

The provider had resolved the concerns for providing safe, caring and well-led services identified at our inspection on 12 April 2017, which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People whose circumstances may make them vulnerable

Good

Updated 7 December 2017

The provider had resolved the concerns for providing safe, caring and well-led services identified at our inspection on 12 April 2017, which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People experiencing poor mental health (including people with dementia)

Good

Updated 7 December 2017

The provider had resolved the concerns for providing safe, caring and well-led services identified at our inspection on 12 April 2017, which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.