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Cornford House Surgery Good Also known as Dr C M Bennett and Partners

Inspection Summary


Overall summary & rating

Good

Updated 4 October 2017

Letter from the Chief Inspector of General Practice

This inspection was an announced focused inspection carried out on 7 September 2017 to confirm that the practice had carried out improvements that we identified in our previous inspection on 11 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is still rated as good, and requires improvement for the safe domain. Our key findings were as follows:

  • The systems and processes to systematically record safety alerts had been improved and showed the alerts had been recorded, actions had been taken, and learning shared. This had improved the oversight of safety.
  • Annual infection prevention and control audits had been undertaken. However, we found out of date items in a clinical room and there was no system in place to check expiry dates of equipment.
  • We reviewed four personnel files and found appropriate recruitment checks had been undertaken prior to employment.
  • We found that there was a system to code patient records on the clinical system for children who did not attend a hospital appointment.
  • We reviewed three policies and found them to be up-to-date and reflective of current practice.
  • We reviewed the system for staff appraisals and found there was a comprehensive log to track when appraisals were due. We checked five staff appraisals and found these had all been completed in the last year.
  • The practice had improved the support offered to carers. There were leaflets in the waiting room which signposted carers to support groups and the practice had developed a ‘carer’s prescription’. This ensured that if a carer became unwell, the practice had systems in place to support both the carer and the person being cared for. The practice had identified 54 patients as carers (0.5% of the practice list).
  • The practice had recognised that results from the GP patient survey, published in July 2017, were in line with or below local and national averages for access. The practice had previously been using locum GPs but had employed two new partners in June 2017 to improve continuity of care. The practice had also employed a minor illness nurse. Other details of the action plan to improve patient satisfaction were; employing an emergency care practitioner, employing a pharmacist and changing the phone lines to a queue based system. They planned to complete a patient survey to assess whether their action plan was effective. The practice planned to complete these actions by the end of 2017. We spoke with nine patients on the day of inspection and eight of these were satisfied with access to the surgery. One reported difficulty accessing the same GP for continuity.

The areas where the provider should make improvements:

  • Continue to proactively identify and offer support to carers.

  • Continue to assess the impact of improvements made relating to patient’s access to services.

  • Implement a system to monitor expiry dates of equipment in clinical rooms.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 4 October 2017

  • The systems and processes to ensure safe management of patient safety alerts had been improved.
  • There were up to date infection prevention and control audits and appropriate action had been taken in response to these. However, we found out of date items in a clinical room there was no system in place to check expiry dates of equipment. The out of date bandages were removed immediately and the provider reported a system would be implemented.
  • We reviewed four personnel files and found appropriate recruitment checks had been undertaken prior to employment.
  • We found there was a system to code patient records on the clinical system for children who did not attend a hospital appointment to ensure they were followed up appropriately.
  • We reviewed three policies and found them to be up-to-date and reflective of practice.

Effective

Good

Updated 28 September 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were generally in line with the clinical commissioning group (CCG) and national averages.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was evidence of appraisals and personal development plans for all staff however, some had not been completed annually.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 28 September 2016

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice in line with 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 28 September 2016

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.
  • Some patients who completed the Care Quality Commission comment cards and those we spoke with told us they did not find it easy to make an appointment with a named GP however urgent appointments were available the same day. The national GP patient survey results were published on 7 July 2016. The results showed that 49% of patients who responded said they usually get to see or speak to their preferred GP compared to the CCG and national average of 59%. The practice had since made some changes to the on-line appointment booking system.

Well-led

Good

Updated 28 September 2016

The practice is rated as good for being well-led.

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.
  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings. There were policies which were in need of review and required updated information, the practice had identified this and had sourced an organisation to write some new policies for them.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken.
  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active but was mainly associated with the branch surgery in Fulbourn.
  • There was a strong focus on continuous learning and improvement at all levels.
Checks on specific services

Older people

Good

Updated 4 October 2017

The provider had resolved the concerns for providing safe services identified at our inspection on 7 September 2017, which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People with long term conditions

Good

Updated 4 October 2017

The provider had resolved the concerns for providing safe services identified at our inspection on 7 September 2017, 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 4 October 2017

The provider had resolved the concerns for providing safe services identified at our inspection on 7 September 2017, 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 4 October 2017

The provider had resolved the concerns for providing safe services identified at our inspection on 7 September 2017, 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 4 October 2017

The provider had resolved the concerns for providing safe services identified at our inspection on 7 September 2017, 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 4 October 2017

The provider had resolved the concerns for providing safe services identified at our inspection on 7 September 2017, which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.