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Archived: Woolsthorpe Surgery Good

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Reports


Inspection carried out on 20 April 2017

During an inspection to make sure that the improvements required had been made

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 carried out on 21 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Woolsthorpe Surgery on 21 September 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • There was a system in place for reporting and recording significant events. We found that they had been reviewed in a timely manner but the system still required some improvement to ensure that the investigations were detailed and actions were identified and implemented
  • Risks to patients were assessed and well managed.
  • We saw that the process for ensuring medication reviews were conducted and recorded was not effective.
  • Where medicines were being prescribed by secondary care we saw evidence that the health care professionals in the practice were not always alerted to this

  • 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.
  • 97% of patients said they had confidence and trust in the last GP they saw compared to the CCG average of 96% and the national average of 95%).

  • 93% of patients said the last GP they spoke to was good at treating them with care

  • 100% of patients said they found the receptionists at the practice helpful compared to the CCG average of 89% and the national average of 87%).

  • Patients told us the practice provided an excellent and professional service. Staff were caring, respectful and very helpful and treated patients with dignity.
  • 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’.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • 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.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:-

  • Embed a proper and safe system for the management of medicines. For example, the process for medicine reviews and medicines prescribed by secondary care.

  • Review the use of the error log in the dispensary to ensure near miss errors are consistently recorded and reviewed to identify trends and potential risks

The areas where the provider should make improvement are:

  • Continue to embed the process for significant events and ensure investigations are detailed and actions identified.

  • Complete the review of the practice Infection control policy to ensure that it provides the appropriate guidance to staff.

  • Complete an Infection control action plan to ensure all actions are completed and document cleaning spot checks carried out on a regular basis.

  • Complete the infection control training for GPs who work at the practice.

  • Update SOPs when processes within the dispensary are altered to ensure all staff are aware of their responsibilities.

  • Ensure verbal complaints are documented and discussed as per the practice policy.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice