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Inspection carried out on 25 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Dr Susanne Senhenn on 25 November 2015. Breaches of legal requirements were found during that inspection within the effective domain. After the comprehensive inspection, the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:

  • Ensure that mandatory training for staff is completed and monitored to ensure that time frames for renewal do not lapse. This included ensuring staff had completed relevant for fire safety, infection control and information governance.

We undertook a focused inspection on 25 May 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. The provider was now meeting all requirements and was rated as Good under the effective domain. This report only covers our findings in relation to those requirements.

  • Mandatory training for staff had been completed. The practice had a new training matrix and used calendar reminders for the renewal of staff training. Staff had completed training for fire safety, infection control and information governance.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 25 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at 25 November 2015. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Data showed patient outcomes were below or average for the locality. However, on the day of the inspection the practice was able to provide evidence that they were performing better in previously low areas and was in line with other CCG and national practices for the same period.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • 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.
  • Urgent appointments were available on the day they were requested. However, some patients told us that they sometimes had to wait for non-urgent appointments or to see the GP of their choice.
  • 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.
  • There were gaps in some staff yearly training.
  • Three members of non clinical staff were receiving external training in order to develop skills and knowledge. For example, BTEC Level 2 in Customer Services and BTEC Level 3 Diploma in Management.
  • Good health was promoted by the practice including self-management through the use of on line review forms.

We saw an area of outstanding practice:

  • The practice had reviewed patient access and had in place 7:30 am fasting blood tests with the practice nurses
  • The practice was able to offer evening appointments (until 9:30pm) and weekend appointments to all their patients. (The practice was part of a hub of doctors’ practices that jointly ran the evening and weekend services)

However there was an area of practice where the provider must make improvements:

  • Ensure that mandatory training for staff is completed and monitored to ensure that time frames for renewal do not lapse. This includes ensuring staff have completed relevant training for fire safety, infection control and information governance

In addition the provider should:

  • Continue to review QOF scores to address any clinical coding issues or exception reporting which is outside the national and regional averages
  • Continue to review patient access and address low scores in patient satisfaction surveys
  • Review systems in place for patient flu vaccinations
  • Review the frequency of multi-disciplinary meetings
  • Review who attends staff meetings
  • Review understanding of the whistleblowing policy

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 25 February 2014

During an inspection looking at part of the service

We visited Dr Susanne Senhenn to look at the care and treatment provided to people who used the service. This was a follow up visit to see if the service had made improvements to their safeguarding and recruitment processes after our initial visit in December 2013.

We saw that systems were in place to safeguard children and adults from abuse. There was information on display that informed staff of the appropriate agencies to contact should abuse be suspected.

We saw that the provider had carried out a review of staff files. There was now a system in place to ensure the required information was obtained before people were employed at the service. They ensured staff were of good character and had the necessary skills and experience to meet the needs of people that used the service.

Inspection carried out on 3 December 2013

During a routine inspection

We visited Dr Susanne Senhenn to look at the care and treatment provided to people who used the service. During our inspection we spoke with seven people who had used the service. One of which was a member of the patient participation group. We also spoke with six of the staff.

All of the people we spoke with were very happy with the service they received. However all of them were unhappy with the telephone system for booking appointments and the car parking facilities.

People told us that they felt respected by staff, and were able to take part in decisions about their treatment. One person said �They do their best to get to the bottom of my problem.� Another person told us �Staff are always polite, kind and respectful.�

People told us that they felt their needs had been met by the service. People told us they never felt rushed by the doctors or nurses during their appointments. One person said �The doctors seem to know me when I come here. On the whole it is a very good service.�

We saw that systems were in place to safeguard children and adults from abuse. However not all of the staff could describe which outside agency safeguarding concerns should be reported to.

We saw that some recruitment information in the staff records was not available at the time of our visit.

There was a system in place for recording complaints. Where complaints had been received we saw that the provider had investigated fully, and responded to the person who made the complaint.