16 February 2017
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Elsdon Avenue Surgery 16 February 2017. Overall, the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
- Staff understood their responsibilities to raise concerns and report incidents and near misses in the practice.
- Risks to patients were assessed and well managed.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
- The practice used the information collected for the Quality and Outcomes Framework (QOF), to monitor and improve outcomes for patients. The practice’s overall achievement, for 2015/16, was better than the local clinical commissioning group (CCG) and England averages.
- 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 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.
- There was a clear leadership structure and staff felt supported by management. This was underpinned by strong, cohesive teamwork and good levels of staff satisfaction.
- 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 regulation.
We saw two areas of outstanding practice:
- New partners had become involved in the practice and they had been very active in engaging their staff with the changes that were required. The practice kept a “staff worry list” that recorded staff issues so that the practice could set priorities and support staff during the any changes required. Staff we met were engaged and supportive of this process.
- The practice recognised how critical it was to support patients who were also carers. The practice had identified 3.8% of their patient list were carers and this had increased over the past 12 months from 1.9% of their patient list.
There was an area where the provider needs to make improvements.
The provider should:
- Review their risk assessment that led to their decision not to have a defibrillator on the premises.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice