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Inspection Summary


Overall summary & rating

Good

Updated 23 April 2018

Letter from the Chief Inspector of General Practice

This practice is rated as good overall. (At the previous inspection undertaken in October 2014, the practice also received a good overall rating)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Elmwood Medical Centre on 5 March 2018. This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

  • There was a clear leadership structure and staff told us they felt well-supported by the partners and practice manager. We observed the positive impact this had in establishing a well-integrated practice team with low staff turnover and high morale.
  • GPs and practice staff worked effectively as a cohesive team and provided personalised and responsive care to their patients.
  • There was an emphasis on a patient centred approach in all aspects of the practice’s work. This was underpinned by the practice’s values.
  • Results from the 2017 national GP patient survey showed that the practice had performed either above or in line with local and national averages regarding patient experience. The results had increased in 19 of the 23 indicators since the last survey was undertaken in 2016.
  • The national GP survey showed that 88% of patients who responded would recommend the surgery to someone new to the area compared with the clinical commissioning group (CCG) average of 81% and the national average of 77%. This was reinforced by the Care Quality Commission (CQC) comment cards completed by patients prior to our inspection, which reflected that patients were highly satisfied with the care they had received.
  • The practice had a strategy and forward vision. They worked with their local CCG and practices to maximise improvements in primary care for local patients. For example, the practice were seeking a solution to NHS England’s requirementto ensure that patients had enhanced access to GP services, including appointments during evenings via an 8-8 service, and the provision of appointments at the weekend and bank holidays.
  • There was a focus on continuous learning and improvement at all levels of the organisation. Staff training records were up to date, and regular appraisals encouraged development at all levels.
  • The practice had an established quality improvement programme. This included a regular audit programme which demonstrated improvements in outcomes for patients.
  • We found that the procedure for checking medicines within the practice was not sufficiently robust and we discovered two items of medicines and consumables that had exceeded their expiry date.
  • The practice was able to demonstrate compliance with health and safety legislation. However, we observed one piece of broken equipment which had not been labelled or removed from a clinical room.
  • The practice encouraged and supported staff to report incidents, although we found that there were generally low levels of incident reporting in the practice. There was some scope to enhance investigations into incidents and to share learning earlier and more widely.

The areas where the provider should make improvements are:

  • Strengthen procedures to check for out of date medicines and consumables.
  • Review the process for investigating incidents and sharing learning from significant events with all team members.
  • Review the procedure for labelling and removing any broken equipment from clinical areas.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 23 April 2018

Effective

Good

Updated 23 April 2018

Caring

Good

Updated 23 April 2018

Responsive

Good

Updated 23 April 2018

Well-led

Good

Updated 23 April 2018

Checks on specific services

People with long term conditions

Good

Updated 23 April 2018

Families, children and young people

Good

Updated 23 April 2018

Older people

Good

Updated 23 April 2018

Working age people (including those recently retired and students)

Good

Updated 23 April 2018

People experiencing poor mental health (including people with dementia)

Good

Updated 23 April 2018

People whose circumstances may make them vulnerable

Good

Updated 23 April 2018