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Dr Helen Osborn Good Also known as Courtyard Surgery

Inspection Summary


Overall summary & rating

Good

Updated 24 May 2017

Letter from the Chief Inspector of General Practice

On

14 September 2016 we carried out a comprehensive inspection at Dr Helen Osborn,

which is also known as Courtyard Surgery. Overall the practice was rated as

requires improvement. Specifically, the practice was found to be good for

providing safe, caring and responsive services, and requires improvement for

effective and well led. We told the practice they must:

  • Ensure

    actions plans are completed for issues identified in infection control audits.

  • The

    practice must ensure they use quality improvement methods, including clinical

    audit, to monitor quality and to make improvements within the practice and

    ensure that learning from these is appropriately discussed and shared with

    practice staff.

  • The

    practice must keep records of all essential training received by staff.

Following

the inspection the provider sent us an action plan that set out the changes

they would make and subsequently supplied information to confirm they had

completed the actions.

This

focused desk based inspection was undertaken on 25 April 2017 to ensure that

the practice was meeting the regulation previously breached. For this reason we

have only rated the location for the key questions to which this related. This

report should be read in conjunction with the full report of our inspection on 14

September 2016, which can be found on our website at

www.cqc.org.uk

.

The practice is now rated as good

for the provision of effective and well-led services. The overall rating is now

good. Our key findings were as follows:

  • An

    infection control audit had been completed in January 2017 and an action plan

    set out follow up actions that had been completed.

  • There

    had been four clinical audits completed since our inspection in September 2016.

  • The

    practice had a planned schedule for audits and repeat audits.

  • The

    practice was keeping records of all essential training received by staff.

The area where the provider should

make improvement are:

  • Review

    the practice system of meetings and communications to ensure they meet the

    regulatory requirements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 30 December 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events.

  • When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.

  • The practice had systems, processes and practices in place to keep patients safe and safeguarded from abuse.

    However, there was no evidence of an action plan following the last infection control audit undertaken in January 2016, which meant the practice could not be sure any actions identified by the audit had been completed.

  • Risks to patients were assessed and well managed.

  • The practice had arrangements in place to respond to emergencies and major incidents.

Effective

Good

Updated 24 May 2017

When

we visited Dr Helen Osborn on 14 September 2016 to carry out a comprehensive

inspection, we found the practice required improvement for the provision of

effective services because:

  • There was insufficient

    evidence of quality improvement activity including clinical audit.

  • There was no evidence that

    any staff other than the lead GP had received training in the Mental Capacity

    Act 2005.

We undertook a desk-based follow up inspection of the

service on 25 April 2017 to review the actions taken by the practice to improve

the quality of care and to confirm that the practice was now meeting legal

requirements. We saw evidence that;

  • The practice had provided evidence

    of quality improvement. There had been four clinical audits commenced since our

    inspection in September 2016 and reviews where planned.

  • The practice had a planned

    schedule for audits and repeat audits.

  • All staff had received

    training in the Mental Capacity Act 2005.

     

The practice is now rated as good for providing safe services.

Caring

Good

Updated 30 December 2016

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care.

  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • Information for patients about the services available was easy to understand and accessible.

  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Good

Updated 30 December 2016

The practice is rated as good for providing responsive services.

  • The practice reviewed the needs of its local population and engaged with the NHS England Area Team and Wiltshire Clinical Commissioning Group to secure improvements to services where these were identified.

  • 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.

  • Results from the national GP patient survey showed that patient’s satisfaction with how they could access care and treatment was higher than local and national averages. For example, 98% of patients said they could get through easily to the practice by phone compared to the CCG average of 80% and national average of 73%.

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

Well-led

Good

Updated 24 May 2017

When we visited Dr Helen Osborn on 14 September 2016 to carry out a comprehensive inspection, we found the practice required improvement for the provision of well-led services because:

  • There were no regular meetings when all GPs were present.

  • Not all complaints had been discussed at the practice meetings.

We undertook a desk-based follow up inspection of the service on 25 April 2017 to review the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements. We saw evidence that;

  • Complaints and significant events were discussed at practice meetings and minutes shared with staff unable to attend. They were introducing a system for staff to confirm they had read the minutes of meetings they were unable to attend.

  • The practice had two part-time GPs who worked on different days and it was not possible to hold routine meetings where all GPs attended. However they had reviewed how they managed meetings to ensure they had an effective system of communication.

The practice is now rated as good for providing well-led services.

Checks on specific services

People with long term conditions

Good

Updated 24 May 2017

We did not inspect the population groups as part

of this inspection. However, the provider had resolved the concerns for

effective and well-led services identified at our inspection on 14 September

2016 which applied to everyone using this practice, including this population

group. The population group ratings have been updated to reflect this.

Families, children and young people

Good

Updated 24 May 2017

We did not inspect the population groups as part

of this inspection. However, the provider had resolved the concerns for

effective and well-led services identified at our inspection on 14 September

2016 which applied to everyone using this practice, including this population

group. The population group ratings have been updated to reflect this.

Older people

Good

Updated 24 May 2017

We did not inspect the population groups as part

of this inspection. However, the provider had resolved the concerns for

effective and well-led services identified at our inspection on 14 September

2016 which applied to everyone using this practice, including this population

group. The population group ratings have been updated to reflect this.

Working age people (including those recently retired and students)

Good

Updated 24 May 2017

We did not inspect the population groups as part

of this inspection. However, the provider had resolved the concerns for

effective and well-led services identified at our inspection on 14 September

2016 which applied to everyone using this practice, including this population

group. The population group ratings have been updated to reflect this.

People experiencing poor mental health (including people with dementia)

Good

Updated 24 May 2017

We did not inspect the population groups as part

of this inspection. However, the provider had resolved the concerns for

effective and well-led services identified at our inspection on 14 September

2016 which applied to everyone using this practice, including this population

group. The population group ratings have been updated to reflect this.

People whose circumstances may make them vulnerable

Good

Updated 24 May 2017

We did not inspect the population groups as part

of this inspection. However, the provider had resolved the concerns for

effective and well-led services identified at our inspection on 14 September

2016 which applied to everyone using this practice, including this population

group. The population group ratings have been updated to reflect this.