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Inspection Summary


Overall summary & rating

Good

Updated 15 March 2018

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection October 2015 – Good)

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? - Outstanding

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 Fryern Surgery on 21 October 2015. The overall rating for the practice was good with a rating of requires improvement for the safe key question. The full comprehensive report on the October 2015 inspection can be found by selecting the ‘all reports’ link for Fryern Surgery on our website at www.cqc.org.uk.

This inspection was a further announced full comprehensive inspection carried out on 17 January 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in October 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At this inspection we found:

  • Health and safety risk assessments had been reviewed since the past inspection and all actions completed. Regular water temperature checks were being completed for legionella testing.

  • Security of the vaccine fridges had been increased with new locks on the fridge doors and located in treatment rooms with lockable doors.

  • The practice had received a large influx of patients registering with the practice following closure of a neighbouring practice in November 2017.

  • 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.

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

  • Staff involved and treated patients with compassion, kindness, dignity and respect.

  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw one area of outstanding practice:

  • There was a strong leadership team who had a focus on succession planning and were able to motivate and encourage staff to help them achieve their vision. For example, staff spoke highly of the leadership team and the support given by them and as such were driven to support the leaders in achieving the vision and strategy. The practice had absorbed over 3000 patients following the closure of a neighbouring practice. The leadership team had foreseen issues around the management of this transition and implemented a strategy which included a full review of each new patients care records and coding system to ensure that patients were correctly coded in line with those used by the practice for existing patients. Staff were happy to work additional hours to complete these tasks as they felt involved in and believed in the strategy.

The areas where the provider should make improvements are:

  • Continue with plans to seek additional secure storage space for patient records.

  • Review staff training records to ensure all staff have a documented record of all necessary training (including informal training delivered in-house).

  • Review ways to increase feedback obtained from the patient representation group and consider the need to develop the virtual patient reference group to into a formal meeting format.

  • Consider ways to capture informal complaints in order to monitor themes and trends.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 15 March 2018

Effective

Good

Updated 15 March 2018

Caring

Good

Updated 15 March 2018

Responsive

Good

Updated 15 March 2018

Well-led

Outstanding

Updated 15 March 2018

Checks on specific services

People with long term conditions

Good

Updated 15 March 2018

Families, children and young people

Good

Updated 15 March 2018

Older people

Good

Updated 15 March 2018

Working age people (including those recently retired and students)

Good

Updated 15 March 2018

People experiencing poor mental health (including people with dementia)

Good

Updated 15 March 2018

People whose circumstances may make them vulnerable

Good

Updated 15 March 2018