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Albert Road & Britannia Village Surgery Good

Inspection Summary


Overall summary & rating

Good

Updated 16 July 2018

We carried out an announced comprehensive inspection at Albert Road & Britannia Village Surgery on 3 May 2017. The overall rating for the practice was good. However, the rating for the practice providing caring services was requires improvement and we found five areas where the provider should improve. The full comprehensive report on the 3 May 2017 inspection can be found by selecting the ‘all reports’ link for Albert Road & Britannia Village Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 26 June 2018 to assess whether the provider was meeting legal requirements and areas it should improve that we identified in our previous inspection on 3 May 2017. This report covers our findings in relation to improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

  • Actions identified during risk assessments such as fire safety were remedied in a timely manner to mitigate the risk of harm to patients and staff.
  • Locum GPs were trained to child protection level three as per statutory guidance.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Rates for childhood immunisations uptake and dementia reporting had improved.
  • There was an effective process for managing cervical screening.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 19 June 2017

The practice is rated as good for providing safe services.

  • From the sample of documented examples we reviewed, we found there was an effective system for reporting and recording significant events; lessons were shared to make sure action was taken to improve safety in the practice.

  • There were procedures for assessing, monitoring and managing risks to patient and staff safety, however we found actions identified during fire risk assessments had not been completed in a timely manner. Following the inspection we received evidence that all the identified actions had been remedied.

  • Staff demonstrated they understood their responsibilities and all had received training on safeguarding children and vulnerable adults relevant to their role with the exception of a locum GP who had received level two safeguarding training.

  • A notice in the waiting room advised patients that chaperones were available if required. All staff who acted as chaperones were trained for the role and had received a Disclosure and Barring Service (DBS) check.

  • The practice had adequate arrangements to respond to emergencies and major incidents including an up to date Business Continuity Plan.

Effective

Good

Updated 19 June 2017

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework showed patient outcomes were at or above average compared to the national average.

  • Medicines and Healthcare Products Regulatory Agency (MHRA alerts) were received by the practice pharmacist who cascaded to the wider clinical team including locum GPs.

  • Staff were aware of current evidence based guidance.

  • Clinical audits demonstrated quality improvement.

  • Staff had the skills and knowledge 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.

  • Information about patients’ outcomes was used to make improvements to safer care such as medicine management including prescribing and medication reviews.

  • End of life care was coordinated with other services involved.

  • Immunisation rates were mixed for all standard childhood immunisations, however the practice had put systems in place to improve uptake rates.

Caring

Good

Updated 16 July 2018

We rated the practice as good for caring.

At our previous inspection on 3 May 2017, we rated the practice as requires improvement for providing caring services due to its below average GP Patient satisfaction results. We found there was insufficient action to improve and review patient outcomes relating to GPs and practice nursing care.

We told the practice it should improve in respect of these issues and found arrangements had improved when we undertook a follow up inspection of the service on 26 June 2018.

Kindness, respect and compassion

The most recent data GP Patient Survey results published July 2017 reflected survey data collected January to March 2017 and contained some scores that were below average. However, this data was collected prior to our previous inspection 3 May 2017 and therefore did not reflect patient’s experiences since 3 May 2017. At this inspection, 26 June 2018 the practice had used it’s GP Patient survey results to inform improvements and had conducted its own surveys to assess outcomes in terms of patient experiences.

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.

Involvement in decisions about care and treatment

  • The practices GP patient survey results were in line with local and national averages except for one score that the practice had acted to improve and evaluate improvements.

Please refer to the evidence tables for further information.

Responsive

Good

Updated 19 June 2017

The practice is rated as good for providing responsive services.

  • The practice understood its population profile and had used this understanding to meet the needs of its population. For example, appointments were offered on Saturdays for patients who could not attend during normal opening hours

  • The practice took account of the needs and preferences of patients with life-limiting conditions, including patients with a condition other than cancer and patients living with dementia.

  • Results from the national GP patient survey showed that patient’s satisfaction with how they could access care and treatment was comparable in most areas to local and national averages.

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

  • Information about how to complain was available and evidence from 15 examples reviewed showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 19 June 2017

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

  • The practice had a clear vision and that was to work in a multidisciplinary team to improve access to patients. Staff were clear about the vision and their responsibilities in relation to it.

  • There was a clear leadership structure and staff felt supported by management. The practice had policies and procedures to govern activity and held regular governance meetings.

  • The practice approach was underpinned by visible leadership, service stabilisation and service improvement.

  • Staff had received inductions, annual performance reviews and attended staff meetings and training opportunities.

  • Management encouraged a culture of openness and honesty. The practice had systems for being aware of notifiable safety incidents and sharing the information with staff and ensuring appropriate action was taken.

  • The practice proactively sought feedback from staff and patients and we saw examples where feedback had been acted on. The practice engaged with the patient participation group.

  • There was a focus on continuous learning and improvement at all levels. Staff training was a priority and was built into staff rotas.
Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good