Archived: Stoneleigh Surgery

Letter from the Chief Inspector of General Practice

We previously carried out an announced inspection of this practice on 28 April 2016. Breaches of legal requirements were found. Overall, we rated the practice as requires improvement.

After the comprehensive inspection the practice wrote to us to say what they would do to address four identified breaches of regulation. We undertook this comprehensive inspection on 8 November 2016 to check that the practice had followed their plan and to confirm that they now met legal requirements. You can read the report from our last comprehensive inspection and our focused inspection by selecting the ‘all reports’ link for Stoneleigh Surgery on our website at www.cqc.org.uk.

Overall the practice is now rated as good.

Our key findings across all the areas we inspected were as follows:

• The practice had taken action to address the concerns raised at the CQC inspection in April 2016. They had developed a clear vision, strategy and plan to deliver high quality care and promote good outcomes for patients.
• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• 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.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Stoneleigh Surgery on 28 April 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses. However, we found that the practice did not have a structured process in place for them, or feedback or learning from significant events.
• There was no system in place to manage patient safety alerts.
• Risks to patients were not always assessed or well managed. For example, some of the medication in the GPs bags were out of date, there was no legionella risk assessment and there were no regular fire drills.
• There was a recruitment policy in place and appropriate recruitment checks had been carried out for staff except for one of the nursing staff who had not received a DBS check.
• Patients’ needs were assessed and care was planned and delivered, however, there was no overall system in place for the practice to follow relevant and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) best practice guidelines.
• Data showed patient outcomes were above average for the locality. For example the overall Quality and Outcomes Framework (QOF) score for 2014/15 showed the practice had achieved 98.4% of the total number of points available to them compared to the national average of 94.8%.
• Staff were consistent and proactive in supporting patients to live healthier lives through a targeted approach to health promotion. Information was provided to patients to help them understand the care and treatment available
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice had a system in place for handling complaints and concerns; however, these were not responded to formally in writing or acknowledged.
• The practice provided good access to appointments for patients. Patients told us they were able to get an appointment with a GP when they needed one, with urgent appointments available on the same day.
• Disabled facilities were limited due to constraints of the building; however the practice had taken steps to provide what services they reasonably could for patients with disabilities.
• The GP partners were not working together as a team or involved in the day to day running of the practice. However, staff did feel supported by management. The practice sought feedback from staff and patients, which they acted on.
• The practices ethos complied with the requirements of the Duty of Candour. However, the practices’ record keeping process for significant events did not support the requirements of Duty of Candour.

The areas where the practice must make improvements are;

• Ensure there is structured feedback and learning from significant events.
• Ensure there is a system in place to manage patient safety alerts.
• Ensure there is a system in place to follow relevant and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) best practice guidelines.
• Ensure safe management of medicines, having a system in place to manage medication in the GPs bags and record the numbers of the pre-printed prescription stock which has been distributed in the practice in accordance with national guidance.
• Ensure DBS checks are carried out where appropriate.

The areas where the provider should make improvements are:

• Make the telephone numbers of the local safeguarding contacts readily available to staff.
• Consider updating the locum induction pack to contain current and comprehensive information for locum GPs working at the practice.
• Carry out a legionella risk assessment.
• Put systems in place for taking adequate written consent for some of their minor operations.
• Follow the practice complaints procedure and reply to complaints formally in writing where appropriate.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice