You are here

Archived: Woolsthorpe Surgery Good

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 15 May 2017

Letter from the Chief Inspector of General Practice

This inspection was an announced focused inspection carried out on 20 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 21 September 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good

Our key findings were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

  • The system in place for medication reviews and the management of medicines prescribed by secondary care had been reviewed and effective processes were now in place.

  • The infection control policy had been reviewed and updated to ensure it provided appropriate guidance to staff.

    All staff had now completed

    infection control training.

  • An infection control action plan was in place and reviewed on a regular basis. Cleaning spot checks were regularly carried out.

  • Processes were in place to capture verbal complaints and comments received at the surgery. Actions were taken were appropriate.

  • Dispensary competencies had been reviewed and a process was in place to document any issues where appropriate.

  • There was a clear leadership structure and staff felt supported by management.

  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Ensure significant events have enough clinical detail documented to demonstrate appropriate details and information are in place.

  • Dispensary visit reports need to have near misses documented and discussed as detailed in the practice policy.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 15 May 2017

The practice is rated as good for providing safe services.

  • There was a much improved system in place for reporting and recording significant events. We found that the system had been updated. Recording and investigations were detailed and actions were identified and implemented. However more evidence in respect of clinical events needed to be added to the record of events. We saw evidence that lessons were shared to make sure action was taken to improve safety in the practice.

  • The practice had undertaken SEA training with all staff to ensure they understood their responsibilities to raise concerns, and to report incidents and near

  • The system in place for medication reviews and the management of medicines prescribed by secondary care had been reviewed and effective processes were now in place.

  • Systems in place for infection prevention and control were now effective.

  • Dispensary significant events were now recorded and regularly discussed. However evidence of discussion and actions for near misses still needed to be recorded.

Effective

Good

Updated 28 October 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were slightly better than the national average. Overall 95.3% for the practice against a national average of 94.7%.

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

  • Clinical audits demonstrated quality improvement.

  • The practice also encouraged its patients to attend national screening programmes for bowel and breast cancer screening. The practice had an uptake of 58% of those eligible for bowel screening which was slightly below the CCG average of 61% and national average of 60%.

  • 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 28 October 2016

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice much higher in most aspects of care.

  • 96% of patients who completed the national GP patient survey would recommend the surgery to someone new in the area.

  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • Information for patients about the services available was easy to understand and accessible.

  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

  • The practice is described by patients and staff as ‘unique’. It is the smallest practice within the SouthWest Lincs CCG and its ethos is ‘a tradition of caring’.

Responsive

Good

Updated 28 October 2016

The practice is rated good for being responsive to people’s needs.

  • The practice worked with the local CCG to plan services and to improve outcomes for patients in the area. Services were planned and delivered to take into account the needs of different patient groups and to help provide flexibility, choice and continuity of care. For example, open access surgeries were available every weekday morning. The practice offered extended hours on Saturday mornings from 9am to 12.30. These alternate between the three Vale Medical Group locations. These appointments are for working patients who could not attend during normal opening hours.
  • Comments cards we reviewed told us that patients said 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.
  • To coincide with a Health Fair organised for October 2016 by the Vale Medical Group PPG the practice have engaged with local primary schools to raise awareness of healthy lifestyles with an art competition.

  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Verbal complaints were not always documented and discussed as per the practice policy. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 15 May 2017

The practice is rated as good for being well-led.

  • Since our inspection in August 2016 we found that the practice had made significant improvements.
  • Woolsthorpe Surgery is one of three locations in Vale Medical Group. The group is committed to preserve and enhance its good reputation for being a traditional and caring innovative practice.

  • There was a clear leadership structure and staff felt supported by management.

  • The practice had a number of policies and procedures to govern activity and held regular governance meetings.

  • The practice now had an effective governance framework in place.

  • The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken

Checks on specific services

People with long term conditions

Good

Updated 15 May 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 21 September 2016 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 15 May 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 21 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Older people

Good

Updated 15 May 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 21 September 2016 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 15 May 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 21 September 2016 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 15 May 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 21 September 2016 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 15 May 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 21 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.