- GP practice
The Burbage Surgery Also known as Dr Jones and Partners
All Inspections
26 October 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
Burbage surgery was inspected on the 28 and 29th April 2015 when the practice was rated as 'requires improvement' as it was found to require improvement in the four key questions of safe, effective, responsive, and well led; it was rated as good for caring.
The practice submitted an action plan detailing how they would meet the regulations governing providers of health and social care and we carried out a further announced inspection on 26 October 2016.
At our inspection we found the practice had made improvements across the key questions which required improvement: safe, effective, responsive, and well led. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows
- There was a system in place for reporting and recordings events and lessons were learned to make sure action was taken to improve safety in the practice.
- 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.
- Urgent appointments were made available for vulnerable patients and unwell children even where sessions were fully booked.
- The practice had adequate facilities and equipment.
- Appropriate checks were carried out before staff started employment.
- 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.
The practice should:
Consider recording verbal complaints to ensure any potential improvements to patient care are identified and actioned.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
28 and 29 April 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection of The Burbage Surgery, Tilton Road, Burbage, Leicestershire on 28 and 29 April 2015. Overall the practice is rated as requires improvement.
Specifically, we found the practice requiring improvement for providing a safe, effective, responsive and well led service. It also required improvement for providing services for all the population groups. It was good for providing a caring service.
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Patients were at risk of harm because systems and processes were not in place to keep them safe.
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Staff were clear about reporting incidents, near misses and concerns but there was limited evidence of learning and dissemination to staff.
- Data showed patient outcomes were average for the locality. Some clinical audits had been carried out and completed in order to improve patient outcomes. However we did not see evidence that the findings had been disseminated in order to maximise improvement.
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Patients gave us feedback about the practice and were positive about their care. They told us they were treated with compassion and dignity.
- Urgent appointments were usually available on the day they were requested.
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There was a system in place for reporting incidents, near misses or concerns, however evidence of learning and communication to staff was limited.
The areas where the provider must make improvements are:
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Have a system in place to ensure significant events and complaints are investigated fully, identified actions implemented and any learning cascaded to staff.
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Implement a robust system for dealing with safety alerts.
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Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision.
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Ensure staff have appropriate and up to date policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
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Ensure protocol and procedures are in place to ensure regular checks of emergency equipment.
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Ensure arrangements are in place for disposal of pharmaceutical waste and appropriate records kept of medicines to be disposed of.
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Ensure competency checks are carried out annually for dispensary staff.
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Ensure a robust business continuity plan is in place.
Action the provider SHOULD take to improve :
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Embed system to ensure staff appraisals continue annually.
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Ensure policies and procedures introduced relating to the safe storage of medicines are maintained.
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Embed revised infection control procedures.
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Request photographic identification as part of the recruitment process.
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Ensure clinical staff have an awareness of the Mental Capacity Act and Gillick competencies.
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Have in place a schedule of minuted meetings.
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Have a system in place for monitoring training needs.
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Ensure water monitoring is implemented in line with legionella risk assessment.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice