Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at 301 High Street on 3 December 2015. Overall the practice is rated as good.
Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.
Our key findings across all the areas we inspected were as follows
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Staff understood and fulfilled their responsibilities to raise concerns and to report incidents. Information about safety was recorded, monitored, and appropriately reviewed. Learning was applied from events to enhance future service delivery.
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Patients’ needs were assessed and care was planned and delivered following best practice guidance. This was kept under review by the practice which proactively used audit as a way of ensuring that patients received safe and effective care.
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Risks to patients were assessed and well managed. Regular liaison meetings were held with the wider multi-disciplinary team to co-ordinate the provision of effective and responsive care. There was evidence of collaborative working including end of life care and safeguarding.
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All members of the practice team had received an annual appraisal and had undertaken training appropriate to their roles, with any further training needs identified and supported by the practice.
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Results from the national GP survey, and responses to our conversations with patients showed that patients were treated with compassion, dignity and respect, and that they were involved in their care and decisions about their treatment.
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The practice worked closely with other services and organisations in the locality, and across the CCG area to plan and review how services were provided to ensure that they met people’s needs.
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Urgent appointments were available on the day they were requested. However, patients said that they sometimes had to wait a long time to see the GP of their choice.
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There was a clear leadership structure and staff felt supported by management.
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The practice proactively sought feedback from patients, which it acted upon. Patients responding to the national patient survey reported a positive experience at this practice, as did patients we spoke with on the day of our inspection.
However there were areas of practice where the provider should make improvements:
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Whilst internal assessments had been completed around the management of legionella and fire risks, issues identified had not been actioned. There was scope to involve external professionals in the compilation of an action plan, especially with regard to the safe storage of heat emitting equipment in the computer room.
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Regular fire drills should be undertaken.
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There was scope to improve the management of cleaning schedules through formal monitoring.
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Ensure that staff who act as chaperones have been trained in accordance with the recent best practice guidelines.
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Maximise the integration of the new computer system in order that the practice can run clinical searches, provide assurance around patient recall systems, consistently code patient groups and produce accurate performance data.
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A system should be implemented to record action taken in response to MHRA (Medicines & Healthcare products) safety alerts and updates.
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There was scope to assure and improve the effectiveness of care received by patients through referrals audits and prescribing analysis.
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Record verbal complaints in order to widen shared learning.
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Improve the arrangements for the security of blank prescription forms.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice