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Inspection Summary


Overall summary & rating

Good

Updated 15 February 2018

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people living with dementia) - Good

We carried out an announced comprehensive inspection at Heeley Green Surgery on 23 January 2018 as a new provider had registered with CQC to provide regulated activities from this location in September 2017.

At this inspection we found:

  • The practice had conducted safety risk assessments and there were action plans in place to address any risks identified.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence -based guidelines.

  • Staff involved and treated patients with compassion, kindness, dignity and respect and patient feedback was positive about the care they received.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective.
  • There was a clear leadership structure and staff told us they felt respected, supported and valued. They felt part of a team and were proud to work in the practice.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Follow the significant event analysis (SEA) policy when reporting incidents.
  • Review how the clinical meetings are recorded to ensure all in attendance are on the record and review the structure of the notes to ensure all items discussed are captured.
  • Review the shared drive on the practice computer system to ensure the latest policies are accessible to staff.
  • Consider risk assessments in relation to the security of the premises.
  • Consider confidentiality at the front desk with regard to patients approaching the desk on an individual basis.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 15 February 2018

Effective

Good

Updated 15 February 2018

Caring

Good

Updated 15 February 2018

Responsive

Good

Updated 15 February 2018

Well-led

Good

Updated 15 February 2018

Checks on specific services

People with long term conditions

Good

Updated 15 February 2018

Families, children and young people

Good

Updated 15 February 2018

Older people

Good

Updated 15 February 2018

Working age people (including those recently retired and students)

Good

Updated 15 February 2018

People experiencing poor mental health (including people with dementia)

Good

Updated 15 February 2018

People whose circumstances may make them vulnerable

Good

Updated 15 February 2018