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Inspection Summary


Overall summary & rating

Good

Updated 27 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at The Portmill Surgery on 1 March 2017. This was to check that improvements had been made following the breaches of legal requirements we identified from our comprehensive inspection carried out on 22 June 2016. During our inspection in June 2016 we identified regulatory breaches in the safe care and treatment, staffing and governance at the practice.

This report only covers our findings in relation to the areas requiring improvement as identified on inspection in June 2016. You can read the report from this comprehensive inspection, by selecting the 'all reports' link for The Portmill Surgery on our website at www.cqc.org.uk. The areas identified as requiring improvement during our inspection in June 2016 were as follows:

  • Ensure an appropriate system is in place for the safe use of prescription pads, and the management of medicines, including those used in an emergency.
  • Ensure a Legionalla risk assessment is completed by a person competent to carry out the task. Implement any action required following the completion of the risk assessment and complete water temperature checks.
  • Complete an assessment on the control of substances hazardous to health.
  • Ensure that all staff employed are receiving an appraisal and essential training relevant to their role.
  • Ensure an accessible and robust system is in place for receiving and responding to complaints.
  • Create and maintain a record of fire alarm tests and fire drills carried out at the premises.

Our focused inspection on 1 March 2017 showed that improvements had been made and our key findings across the areas we inspected were as follows:

  • The practice had an appropriate system in place for the safe use and management of medicines, including those used in an emergency. Prescription pads were securely stored and an effective system was in place to monitor their use.
  • A legionella risk assessment had been completed by an external company and all of the required work and checks had been managed appropriately.
  • The practice had completed an assessment on the control of substances hazardous to health.
  • All staff members had completed essential training relevant to their role and had received an appraisal.
  • The practice had an effective system in place for receiving and responding to complaints, which was in line with national guidance.
  • Fire alarm tests and fire drills were carried out on a regular basis and the practice and landlord maintained a record of this.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 27 March 2017

At our comprehensive inspection on 22 June 2016, we identified breaches of legal requirements. Improvements were needed to processes and procedures to ensure the practice provided safe services.

During our focused inspection on 1 March 2017, we found the practice had taken action to improve and the practice is rated as good for providing safe services.

  • The practice had an appropriate system in place for the safe use and management of medicines, including those used in an emergency.
  • Prescription pads were securely stored and an effective system was in place to monitor their use.
  • A legionella risk assessment had been completed and all of the required work had been completed. The practice completed ongoing monitoring including water temperature checks.
  • The practice had completed an assessment on the control of substances hazardous to health.
  • Fire alarm tests and fire drills were carried out on a regular basis and the practice maintained a record of this.

Effective

Good

Updated 24 August 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework showed patient outcomes were at or above average for the locality and compared to the national average.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • The practice was proactive in ensuring staff learning needs were met.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 24 August 2016

The practice is rated as good for providing caring services.

  • Data from the National GP Patient Survey results published on 7 January 2016 showed patients rated the practice higher than others for several aspects of care.
  • The practice offered flexible appointment times based on individual needs.
  • 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.
  • The practice held a register of carers with 305 carers identified which was 2% of the practice list. There was a nominated Carers’ champion who provided information about local support groups and services.

Responsive

Good

Updated 24 August 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. For example, the practice participated in the local area winter resilience scheme and offered more appointments. This service had given patients the opportunity to attend the practice for an urgent appointment rather than travel to the local A&E department.
  • Arrangements were in place for trained nurses, from a local practice, to deliver an anticoagulation clinic at the practice on a regular basis.
  • 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.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. The practice had installed automatic entrance doors in May 2015 to improve patient access.

Well-led

Good

Updated 27 March 2017

At our comprehensive inspection on 22 June 2016, we identified breaches of legal requirements. Improvements were needed to processes and procedures to ensure the practice provided well-led services.

During our focused inspection on 1 March 2017, we found the practice had taken action to improve and the practice is rated as good for providing well-led services.

  • The practice had an effective system in place to ensure all staff members completed core training essential to their role.
  • The practice had an appraisal policy and procedure in place and all staff members had received an appraisal within the last 12 months.
  • The practice had an effective system in place for receiving and responding to complaints, which was in accordance with national guidance.
Checks on specific services

People with long term conditions

Good

Updated 27 March 2017

At our comprehensive inspection on 22 June 2016 we found that the practice offered effective care to patients with long term conditions.

However, breaches of legal requirements were identified and improvements needed to be made to ensure the practice provided safe services and was well-led. During our focused inspection on 1 March 2017 we found the practice had taken action to improve. Consequently the practice is rated as good for the care of people with long-term conditions as they received care that was safe and well-led.

Families, children and young people

Good

Updated 27 March 2017

At our comprehensive inspection on 22 June 2016 we found that the practice provided a good service to families, children and young people including those children living in disadvantaged circumstances and who were at risk.

However, breaches of legal requirements were identified and improvements needed to be made to ensure the practice provided safe services and was well-led. During our focused inspection on 1 March 2017 we found the practice had taken action to improve. Consequently the practice is rated as good for the care of families, children and young people as they received care that was safe and well-led.

Older people

Good

Updated 27 March 2017

At our comprehensive inspection on 22 June 2016 we found that the practice offered proactive, personalised care to meet the needs of the older people in its population.

However, breaches of legal requirements were identified and improvements needed to be made to ensure the practice provided safe services and was well-led. During our focused inspection on 1 March 2017 we found the practice had taken action to improve. Consequently the practice is rated as good for the care of older people as they received care that was safe and well-led.

Working age people (including those recently retired and students)

Good

Updated 27 March 2017

At our comprehensive inspection on 22 June 2016 we found that the practice offered a good service to patients of a working age and ensured the needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

However, breaches of legal requirements were identified and improvements needed to be made to ensure the practice provided safe services and was well-led. During our focused inspection on 1 March 2017 we found the practice had taken action to improve. Consequently the practice is rated as good for the care of working age people as they received care that was safe and well-led.

People experiencing poor mental health (including people with dementia)

Good

Updated 27 March 2017

At our comprehensive inspection on 22 June 2016 we found that the practice had systems in place to ensure good care for those patients experiencing poor mental health including those patients with dementia.

However, breaches of legal requirements were identified and improvements needed to be made to ensure the practice provided safe services and was well-led. During our focused inspection on 1 March 2017 we found the practice had taken action to improve. Consequently the practice is rated as good for the care of people experiencing poor mental health as they received care that was safe and well-led.

People whose circumstances may make them vulnerable

Good

Updated 27 March 2017

At our comprehensive inspection on 22 June 2016 we found that the practice held a register of patients living in vulnerable circumstances including those with a learning disability. The practice informed vulnerable patients about how to access support groups and voluntary organisations and staff knew how to recognise signs of abuse in vulnerable adults and children.

However, breaches of legal requirements were identified and improvements needed to be made to ensure the practice provided safe services and was well-led. During our focused inspection on 1 March 2017 we found the practice had taken action to improve. Consequently the practice is rated as good for the care of people whose circumstances may make them vulnerable as they received care that was safe and well-led.