You are here

Inspection Summary


Overall summary & rating

Good

Updated 27 December 2018

We carried out an announced comprehensive inspection at High Street Surgery on 27 June 2018. The overall rating for the practice was good with requires improvement for providing well-led services. The full comprehensive report on the 27 June 2018 inspection can be found by selecting the ‘all reports’ link for High Street Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 4 December 2018 to confirm that the practice had made the recommended improvements that we identified in our previous inspection on 27 June 2018. This report covers our findings in relation to those improvements made since our last inspection.

Overall the practice is rated as good.

Our key findings were as follows:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • There were clear responsibilities, roles and systems of accountability to support good governance and management.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The area where the provider should make improvement is:

  • Continue to review and ensure improvement to the National GP Patient Survey results, including access to the practice by telephone and appointment waiting times.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection areas

Well-led

Good

Updated 27 December 2018

At our previous inspection on 27 June 2018, we rated the practice as requires improvement for providing well-led services as the system in place to ensure all staff members had up-to-date records of vaccinations in line with national guidance required strengthening. Not all staff members had received refresher training on safeguarding children. The practice did not maintain a record of fire drills and did not have a health and safety risk assessment in place. An infection control audit had not been completed on a regular basis. Not all non-clinical staff had a clear understanding of ‘red flag’ sepsis symptoms. Not all non-clinical staff members had received an appraisal within the previous 12 months.

Additionally, we told the practice that they should:

  • Continue to monitor the National GP Patient Survey results including patient waiting times.

At this inspection in December 2018 we found the practice had taken steps to improve their systems and processes and had addressed the areas previously identified as requiring improvement. The practice is now rated as good for providing well-led services.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff members had now received an appraisal and systems were in place to ensure this was undertaken on a regular basis.
  • The practice had reviewed the system in place to monitor staff vaccinations and checks had been carried out in line with national guidance. All staff now had the required checks and records of vaccinations in place relevant to their roles.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control. Staff had access to e-training modules and all staff members had completed safeguarding children training and essential training relevant to their role. The practice had a system in place to ensure ongoing monitoring of this.
  • There was an effective process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had reviewed their fire safety arrangements and had implemented a system to ensure weekly documented checks were completed on the fire alarm system. The practice had undertaken a fire drill in November 2018 and planned to complete this two times a year. A health and safety risk assessment had been carried out in July and October 2018. The practice had created an overarching risk register and had taken action to improve fire safety. For example, the practice had reviewed their security lighting.
  • An infection prevention and control (IPC) audit was completed in October 2018 and systems were now in place to ensure that this was done on a regular basis. Information on IPC had been discussed during staff meetings and the practice was able to demonstrate action taken as a result of IPC monitoring. For example, the practice was in the process of auditing the performance of their cleaning contractor.
  • After our previous inspection in June 2018, the practice had arranged for a GP clinical lead to attend the practice and provide training to all staff members on managing patients with deteriorating health, such as sepsis. Staff members had been given guidance on identifying such patients and information about this was displayed in the practice.
  • Results from the latest National GP Patient Survey published in August 2018 showed 34% of respondents found it easy to get through to this GP practice by phone, compared to the local average of 64% and national average of 70%. 37% of respondents waited 15 minutes or less after their appointment time to be seen at their last general practice appointment. This was a 6% improvement when compared with the National GP Patient Survey results published in July 2017. The practice told us that they were aiming to have their new premises ready by July 2019 and would be recruiting additional clinical and non-clinical staff. Staff told us that they expected these significant changes to have a positive impact on access and patient experience.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good