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Inspection Summary


Overall summary & rating

Good

Updated 13 September 2016

Letter from the Chief Inspector of General Practice

We carried out a desk-based review of evidence requested from The Hawthorns Surgery on 23 August 2016. Overall the practice is rated as good.

During our previous inspection of the practice on 26 November 2015 the practice was rated requires improvement for the safe domain. The practice was issued with one requirement notice for breaches in regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The issues related to legionella risk assessments not being in place and ensuring systems were in place to monitor the use of prescription stationery.

This desk-based review was to assess the action that had been taken by the provider since the last inspection through a review of evidence relating to the issues identified previously. For this reason we have only rated the location for the safe domain. The report should therefore be read in conjunction with the full inspection report published in February 2016.

Through a review of the information sent to us by the provider we found the practice had made changes since their previous inspection in November 2015. We found that robust action had been taken regarding the issues identified at the previous inspection and that the practice was now meeting the requirements of the standards. This meant that the practice was now rated as good in safe domain. All other domains were already previously rated as good.

Specifically we found that since the last inspection:

  • The practice had developed and implemented a robust new policy to monitor the use of prescription stationery.

Risks to patients were assessed and well managed. A legionella risk assessment had been completed and the practice had implemented the recommendations to minimise risk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 13 September 2016

  • Risks to patients were assessed and well managed.
  • We saw evidence to demonstrate that risks related to legionella had now been assessed and processes implemented to minimise risk.
  • Robust systems were now in place to monitor the use of prescription stationery.

Effective

Good

Updated 13 September 2016

Caring

Good

Updated 13 September 2016

Responsive

Good

Updated 13 September 2016

Well-led

Good

Updated 13 September 2016

Checks on specific services

People with long term conditions

Good

Updated 18 February 2016

  • Performance for diabetes related indicators was above the national average (practice average of 90% compared to a national average of 84%).

  • Longer appointments and home visits were available when needed

  • Patients had a personalised care plan or structured annual review to check that their health and care needs were being met.

  • For those patients with more complex needs, we identified that the GPs worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people

Good

Updated 18 February 2016

  • Same day appointments were available for children and those with serious medical conditions.

  • Immunisation rates for childhood vaccinations were above CCG averages. For example, childhood immunisation rates for under two year olds ranged from 92% to 98% and five year olds from 92% to 98% which compared favourably with national rates of 87% to 96% and 85% to 96% respectively.

  • Appointments were available outside of school hours and the premises were suitable for children and babies.

  • The practice had a dedicated sexual health clinic that offered a range of sexual health promotion services and treatments.

  • The practice’s uptake for the cervical screening programme was 81%, which was comparable to the national average of 82%.

Older people

Good

Updated 18 February 2016

  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

  • The percentage of people aged 65 or over who received a seasonal flu vaccination was comparable to the CCG and national averages.

  • Online appointments were available and patients who were housebound. They were also able to submit repeat prescription requests via the phone.

  • Longer appointments were also available for older people when needed.

  • There were disabled facilities, hearing loop and translation services available.

  • The practice had a ramped access and automatic doors for both the front entrance and the back entrance leading onto the car park.

  • There were marked disabled parking bays near the practice.

Working age people (including those recently retired and students)

Good

Updated 18 February 2016

  • The practice was open between 8.15 am and 6.30pm Monday to Friday although extended hours surgeries were not offered at the practice.
  • Patients could book appointments or order repeat prescriptions online.

  • Health promotion advice was available at the practice.

People experiencing poor mental health (including people with dementia)

Good

Updated 18 February 2016

  • Performance for mental health related indicators was above the national average (practice average of 94% compared to a national average of 89%).

  • The practice carried out advance care planning for patients with dementia.

  • The practice had informed patients experiencing poor mental health about how to access various support groups and voluntary organisations.

  • The GP we spoke with had good knowledge of the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.

  • Staff had a good understanding of how to support patients with mental health needs and dementia.

People whose circumstances may make them vulnerable

Good

Updated 18 February 2016

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability and had carried out annual health checks for people with a learning disability.

  • The practice offered longer appointments for patient requiring an interpreter or for those with a learning disability.

  • The practice had policies that were accessible to all staff which outlined who to contact for further guidance if they had concerns about a patient’s welfare.

  • There was a lead and deputy members of staff for safeguarding and we saw evidence to show that staff had received the relevant safeguarding training.

  • Staff members we spoke with were able to demonstrate that they understood their responsibilities with regards to safeguarding.