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Archived: Green Street Surgery Good

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Reports


Inspection carried out on 25 July 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Green Street Surgery on 6 October 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Green Street Surgery on our website at www.cqc.org.uk.

This inspection was a desk based review carried out on 25 July 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 Day Month Year. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

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Overall the practice is now rated as good.

Our key findings were as follows:

  • Clinical audits and re-audits were being carried out to improve patient outcomes.

  • Multi-disciplinary team meetings were being undertaken.

  • A business plan had been developed to underpin the vision for the practice.

  • All policies and procedures had been reviewed and were up to date. Each policy had a lead member of staff assigned to be responsible for monitoring and future updates.

  • The patient participation group had been reinstated and was meeting on a regular basis.

  • An action plan had been developed to address the scores of the national patient survey.

  • Cleaning schedules for clinical equipment was in place. The carpet had been cleaned in March 2017 but has subsequently been replaced with lino.

  • A process had been put in place to identify and support carers.

  • All portable electrical appliances had been tested.

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

The provider should:

  • Look at ways to further identify carers and provide support.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 6 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Green Street Surgery on 6 October 2016. Overall the practice is rated as requires improvement.

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.
  • Risks to patients were assessed and well managed.
  • Data showed some patient outcomes were low compared to the national average. Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.
  • The practice did not have cleaning schedules for the carpets which were within the clinical rooms. Nor were there cleaning schedules for the cleaning of clinical equipment.
  • Care plans were in place for some patients however no care plans were in place for patients on end of life care. the practice responded by saying that there were no patients currently on end of life care but plans would be implemented as necessary.
  • The practice could not identify the number of carers due to a lack of coding on the practice computer system.
  • Multidisciplinary team meetings only took place for older patients.
  • The practice had a vision and set of values but did not have a business plan to support them.
  • The practice found it difficult to organise a meeting of the patient participation group which had not met in over a year.
  • The practice did not have a website but were able to offer online appointment booking.
  • The practice had a number of policies and procedures to govern activity; some were in the process of review.

The areas where the provider must make improvements are:

  • Fully engage in multidisciplinary team meetings.

  • Produce a business plan to support activity.

  • Carry out clinical audits and re-audits to improve patient outcomes.

In addition the provider should:

  • Complete the review of practice policies.

  • Find ways to reinstate the patient participation group.

  • Look at ways to improve national patient survey scores.

  • Complete schedules for the cleaning of carpets in the clinical rooms ans for individual clinical equipment.

  • Undertake a log of prescription pads to ensure security and an audit trail.

  • Ensure carers are identified and correctly coded on the computer system and that systems are put in place to support them.

  • Undertake portable electrical appliance (PAT) testing.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice