The Care Quality Commission
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  • GP practice

Archived: The Meadows Surgery

Overall: Good read more about inspection ratings

Meadow Lane, Thrapston, Kettering, Northamptonshire, NN14 4GD (01832) 734444

Provided and run by:
The Meadows Surgery

Important: The provider of this service changed. See new profile

All Inspections

21 March 2018

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at The Meadows Surgery on 25 July 2017. The overall rating for the practice was requires improvement. The full comprehensive report on the June 2017 inspection can be found by selecting the ‘all reports’ link for The Meadows Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 21 March 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in the regulation that we identified in our previous inspection on 25 July 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The provider had resolved the concerns for responsive and well-led services identified at our inspection on 25 July 2017 which applied to everyone using this practice, including the population groups. The population group ratings have been updated to reflect this. Overall the practice is now rated as good.

Our key findings were as follows:

  • The process to assess, monitor and improve the quality and safety of the services being provided, in particular the meeting structures that supported the governance framework including terms of reference, frequency and appropriateness of notes/minutes were now implemented and formalised.

Additionally where we previously told the practice they should make improvements our key findings were as follows:

  • A review of the immunisation status of clinical and non-clinical staff had been completed. A documented process was evident which ensured eligible staff were protected against transmissible diseases.

  • The practice had strengthened the way they identified and supported carers and was working towards the bronze award for investors in carers GP surgery accreditation which recognised excellence in identifying and supporting carers.

  • A system to record verbal complaints had been introduced in the revised complaints procedure so the practice was able to record and review all sources of complaints, respond appropriately and learn from complaints.

  • The practice had monitored patient feedback especially in relation to access to appointments. A practice commissioned patient satisfaction survey showed increased levels of satisfaction.

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

In addition the provider should:

  • Continue to monitor patient satisfaction in relation to access to appointments paying particular attention to matching capacity of clinical staff available to patient demands.

  • Continue to make patients aware of the different ways appointments could be made, for example online.

  • Continue to monitor the effectiveness of the meeting structures that supported the governance framework including making available protected time for staff to attend meetings, and ways of communicating important changes and developments between scheduled meetings.

  • Complete the review of practice management and ensure practice staff are kept informed of any changed arrangements both interim and permanent.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

25 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Meadows Surgery on 25 July 2017. Overall the practice is rated as requires improvement.

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events. The practice carried out a thorough analysis of the significant events. Staff confirmed lessons learnt were shared but there was no documentation that supported these discussions.
  • The practice had defined and embedded systems to minimise risks to patient safety.
  • GPs and nurses took individual responsibility to keep up-to-date with NICE and other evidence based guidelines and its implementation. Clinical tools available on the electronic patient records and a system called Pathfinder were used to deliver care and treatment but there was no evidence of related discussions at clinical meetings.
  • Data from the Quality and Outcomes Framework (QOF) for 2015/16 showed patient clinical outcomes were below CCG and national averages. However unverified data for 2016/17 obtained from the CCG showed that improvements have been made with predicted achievements of 99% of the total number of points available (541 points out of 545). QOF as demonstrated by the practice for progress so far into 2017/18 showed sustained improvements and was managed by a practice QOF lead.
  • Two first stage audits had been completed. There was a forward schedule of audits which included audit dates for the two first stage audits.
  • Essential mandatory training had been identified and staff had access to appropriate training resources. This included infection control, basic life support, fire safety, safeguarding and information governance.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment. However they also showed dissatisfaction with access to appointments.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a leadership structure and staff felt supported by management.
  • The governance structure included a number of meetings. However some meetings lacked clarity of purpose, frequency, content and formal minutes/notes.
  • The practice proactively sought feedback from staff and patients, which it acted on. There was a patient participation group (PPG) who had a programme of work to support the practice.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must improvement are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care, for example establish a framework to support effective communication for both internal and external colleagues.

The areas where the provider should improvement are:

  • Complete the review of the immunization status of clinical and non clinical staff and ensure a documented process to evidence compliance.
  • Develop a more formal approach to support carers.
  • Develop a system to record verbal complaints.
  • Continue to monitor and ensure improvement to national GP patient survey results, and improve access to appointments.

This service was placed in special measures on 28 January 2016. Sufficient improvements have been made and I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice