Archived: Stonydelph Health Centre

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Stonydelph Medical Practice on 6 September 2017. Overall the practice is now rated as Good.

The practice was formerly known as Dr Yannamani and Dr John’s Surgery, and had previously been inspected on 1 December 2015. Following this comprehensive inspection the overall rating for the practice was Requires Improvement. A breach of the legal requirements was found and a requirement notice was served. The practice provided us with an action plan detailing how they were going to make the required

improvements in relation to:

Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014: Good Governance.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Yannamani and Dr John’s Surgery on our website at www.cqc.org.uk.

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. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• There was a formal system in place to log, review, discuss and act on external alerts, such as the Medicines and Healthcare products Regulatory Agency (MHRA) alerts.
• 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 care and treatment.
• Patients said they were treated with kindness, 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. Improvements were made to the quality of care and access to services as a result of complaints and concerns.
• Data from the national GP patient survey published July 2017 showed patient satisfaction was the same as or above local Clinical Commissioning Group (CCG) and national averages for most areas measured.
• There was a clear leadership structure in place and staff felt supported by the management team. The practice responded positively to feedback from staff and patients.
• The practice had effective procedures for the storage of emergency medicines and regular checks were undertaken to ensure medicines were fit for use.
• Effective systems were in place for identifying and assessing the risks to the health and safety of patients and staff.
• The practice proactively sought feedback from staff and patients, which it acted on.
• Patients found it easy to make an appointment, with urgent appointments available the same day.
• Governance arrangements had improved to include the formalisation of practice staff meetings and a better understanding of practice performance.
• The practice was well equipped to treat patients and meet their needs.
• A programme of clinical audits had been implemented and repeated cycles were planned to monitor quality improvement in patient outcomes. However findings had not always been actioned in a timely manner.

The areas where the provider should make improvements are:

• Identify on the clinical system those patients who are housebound.
• Record that consent has been obtained from the patients when appropriate.
• Implement a call/recall system for those patients with learning disabilities to have annual health checks.
• Review the findings from quality improvement audits to ensure appropriate action is taken.
• Formalise the arrangements for providing pre-booked appointments for male patients to see a male clinician.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice