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Inspection Summary


Overall summary & rating

Good

Updated 1 August 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Meadows Surgery on 2 August 2016. Overall the practice is rated as requires improvement. The full comprehensive report on the 2 August 2016 inspection can be found by selecting the ‘all reports’ link for Meadows Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 18 July 2017 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 on 2 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective and well led services. Overall the practice is now rated as good. All six population groups have also been re-rated following these improvements and are also rated as good.

Our key findings were as follows:

  • The practice had reviewed all their documents, policies and processes used to govern activity to ensure they were practice specific and up to date.

  • The practice had reviewed and improved the arrangements they had in place for the management of infection control and for the assessment, monitoring and minimising of associated risks. This included the monitoring of actions from infection control audits and ensuring they were addressed, and that all cleaning of clinical equipment was recorded.

  • The practice had reviewed it’s systems for the monitoring of staff training and had ensured all staff had received appropriate training to their role including infection prevention control and information governance.

  • Clinical staff were involved in the assessment, monitoring and improvement of the quality and safety of the services being provided.

  • The outcome of patient’s mental capacity to consent to care or treatment was clearly recorded when this had been assessed by a GP or nurse.

    The practice had made improvements to the recording of complaints to enhance efficiency and the management of the process.

  • The practice had improved the way they identified the patients who were also carers which had led to an increase in the number of patients registered as carers on the practice’s list. At the previous inspection, the practice had identified 84 (less than 1% of the practice list) patients as carers. At this inspection we found that the number of patients identified as carers had increased to 145 (approximately 1.5% of the practice’s list).

  • The practice had arrangements to provide regular communication and updates to all staff and this had been reviewed to ensure it benefited part time staff.

We have changed the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well led services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 1 August 2017

At the last comprehensive inspection on the 2 August 2016, we found the practice was not meeting legal requirements for providing safe services. Since our last inspection, the practice had made a number of improvements to address the breaches in regulations we previously identified.

During the inspection in July 2017, we saw the concerns leading to breach of regulation had been addressed. The practice is now rated as good for the provision of safe services.

Specifically, the practice had:

  • Had reviewed and improved the arrangements in place for the management of infection control and for the assessment, monitoring and minimising of associated risks. This included the monitoring of actions from infection control audits and ensuring they were addressed, and that all cleaning of clinical equipment was recorded.

Effective

Good

Updated 1 August 2017

At the last comprehensive inspection on the 2 August 2016, we found the practice was not meeting legal requirements for providing effective services. Since our last inspection, the practice had made a number of improvements to address the breaches in regulations we previously identified.

During the inspection in July 2017, we saw the concerns leading to breach of regulation had been addressed. The practice is now rated as good for the provision of effective services.

Specifically, the practice had:

  • Reviewed it’s systems for the monitoring of staff training and had ensured all staff have received appropriate training to their role including infection prevention control and information governance.

  • Ensured clinical staff were involved in the assessment, monitoring and improvement of the quality and safety of the services being provided including clinical audits.

  • Ensured that the outcome of patient’s mental capacity to consent to care or treatment were clearly recorded when this had been assessed by a GP or nurse.

Caring

Good

Updated 20 February 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care.
  • 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.

Responsive

Good

Updated 20 February 2017

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, they were working with NHS England to consider expansion or a branch surgery to accommodate additional patients following new housing locally.
  • 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. This included a portable hearing loop, disabled facilities and baby changing facilities.
  • The practice regularly attended to the residents of nearby care homes to provide services that included medicine reviews and health checks. We received positive feedback from one of the care home managers about the care and treatment received.
  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 1 August 2017

At the last comprehensive inspection on the 2 August 2016, we found the practice was not meeting legal requirements for providing well-led services. Since our last inspection, the practice had made a number of improvements to address the breaches in regulations we previously identified.

During the inspection in July 2017, we saw the concerns leading to breach of regulation had been addressed. The practice is now rated as good for the provision of well led services.

Specifically, the practice had:

  • Reviewed all their documents, policies and processes used to govern activity to ensure they were practice specific and up to date.

  • The overarching governance framework had improved to ensure, there was oversight and completion of staff training and the recording of consent where a patient’s capacity had been assessed was clearly recorded.
  • Reviewed their arrangements to ensure they provide regular communication and updates to all staff.
Checks on specific services

People with long term conditions

Good

Updated 1 August 2017

The provider had resolved the concerns for safe, effective and well-led identified at our inspection on 2 August 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Families, children and young people

Good

Updated 1 August 2017

The provider had resolved the concerns for safe, effective and well-led identified at our inspection on 2 August 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Older people

Good

Updated 1 August 2017

The provider had resolved the concerns for safe, effective and well-led identified at our inspection on 2 August 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Working age people (including those recently retired and students)

Good

Updated 1 August 2017

The provider had resolved the concerns for safe, effective and well-led identified at our inspection on 2 August 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People experiencing poor mental health (including people with dementia)

Good

Updated 1 August 2017

The provider had resolved the concerns for safe, effective and well-led identified at our inspection on 2 August 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People whose circumstances may make them vulnerable

Good

Updated 1 August 2017

The provider had resolved the concerns for safe, effective and well-led identified at our inspection on 2 August 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.