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Inspection carried out on 21 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall.

(Previous inspection January 2015 - The practice was rated as good overall).

The key questions are rated as:

Are services safe? - Good

Are services effective? - Good

Are services caring? - Good

Are services responsive? - Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People - Good

People with long-term conditions - Good

Families, children and young people - Good

Working age people (including those recently retired and students - Good

People whose circumstances may make them vulnerable - Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Pitshanger Family Practice on 21 December 2017. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether Pitshanger Family Practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • The practice proactively sought feedback from staff and patients, which it acted on.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Review the system in place to improve the management of blank prescription forms.
  • Review and monitor the system in place to ensure all national safety and medicines alerts are received and acted on.
  • Review and improve the systems in place to effectively monitor and improve patient outcomes for patients with long term conditions.
  • Ensure a response to complaints includes information of the complainant’s right to escalate the complaint to the Ombudsman if dissatisfied with the response.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 07 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at 09.30 on 7 January 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, well-led, effective, caring and responsive services. It was also good for providing services for older people, people with long term conditions, families children and young people, working age people including those recently retired, people whose circumstances make them vulnerable, and people experiencing poor mental health (including those with dementia).

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 were assessed and well managed. An external infection control audit had taken place and the practice demonstrated they were compliant with infection control guidelines.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. The majority of staff had received training appropriate to their roles.
  • Information for patients on looking after their health was included in the practice newsletter which was issued four times a year.
  • 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 and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had responded to the results of patient surveys and was offering extended opening hours and had given information to patients on the option of a telephone consultation with a GP at the practice.
  • 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, which it acted on.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should:

  • Ensure all staff are aware of the chaperone policy and the role of the chaperone and ensure training is provided to members of staff who undertake a formal chaperone role.
  • A training and development plan should be put in place for new staff to ensure they have the right skills and knowledge.
  • Provide detailed awareness training for all staff on safeguarding adults at risk.
  • Ensure audit cycles are completed to drive continual improvement.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

 

 

 

CQC Insight

These reports bring together existing national data from a range of indicators that allow us to identify and monitor changes in the quality of care outside of our inspections. The data within the reports do not constitute a judgement on performance, but inform our inspection teams. Our judgements on quality and safety continue to come only after inspection and we will not make judgements on data alone. The evidence tables published alongside our inspection reports from April 2018 onwards replace the information contained in these files.