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Inspection Summary


Overall summary & rating

Good

Updated 20 August 2015

Letter from the Chief Inspector of General Practice

In October 2014 we fund concerns related to the recruitment of staff during a comprehensive inspection of Evergreen Practice. Following the inspection the practice sent us an action plan detailing how they would improve recruitment and undertake necessary staff checks. We carried out desktop review of the Evergreen Practice on 15 July 2015 to ensure these changes had been implemented and that the practice was meeting regulations. Our previous inspection in October 2014 had found breaches of regulations relating to the safe delivery of services. The ratings for the practice have been updated to reflect our findings.

We found the practice had made improvements since our last inspection on 2 October 2014 and they were meeting the regulation relating to the recruitment of staff that had previously been breached.

Specifically the practice was:

  • Operating safe systems in relation to the recruitment of 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 20 August 2015

At our last inspection in October 2014 we found the practice was not undertaking all staff checks required when recruiting employees. In July 2015 we were sent evidence which showed recruitment procedures and staff checks were carried out to ensure that staff were suitable to work in positions of trust and with patients. A recruitment policy had been implemented to ensure that requirements related to the employment of staff were followed.

Effective

Good

Updated 8 January 2015

The practice is rated as good for effective. Data showed patient outcomes were at or above average for the locality. Patients’ needs were assessed and care was planned and delivered in line with local and national guidance. This included assessment of capacity and the promotion of good health. Staff were trained appropriate to their roles and further training needs were identified and planned. The practice staff had participated in appraisals and had opportunities for development in their roles. Multidisciplinary working was evidenced.

Caring

Good

Updated 8 January 2015

The practice is rated as good  for caring. Data showed patients rated the practice higher than others for many aspects of care. Feedback from patients was positive and survey data confirmed this finding. We observed a person centred culture and staff were motivated to offer kind and compassionate care.

Responsive

Good

Updated 8 January 2015

The practice is rated as good for responsive. There was an accessible complaints system with evidence demonstrating that the practice responded quickly to issues raised.  All the feedback we received from patients was positive. The practice was aware of the needs of its registered population. Patients reported good access to the practice and their named GP and with 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.

Well-led

Good

Updated 8 January 2015

The practice is rated as good for well-led. We identified two areas of concern. There was a lack of formal governance arrangements during a period of transition, including staff changes and possible future relocation of the practice. The practice had a number of policies and procedures to govern activity. However, we found the recruitment policy had not been followed. The senior GP had a clear vision for the development of the practice. Staff were confident in the leadership of the GP. The practice team was small and preferred communication to be informal and face to face. Formal regular meetings also took place, although minutes were not readily available. There were systems in place to monitor and improve quality and identify risk. The practice proactively sought feedback from staff and patients and this had been acted upon. The practice had an active patient participation group (PPG). Staff had received induction, regular performance reviews and were supported in their roles.

Checks on specific services

People with long term conditions

Good

Updated 8 January 2015

The practice is rated as good for care provided to people with long term conditions.  All these patients had a named GP and structured annual reviews to check their health and medicine needs were being met. For those people with the most complex needs the named GP worked with the community matron to meet their needs. Practice outcome data showed the practice performed similar to other local practices. Text messages were used to remind patients of their appointment times.

Families, children and young people

Good

Updated 8 January 2015

The practice is rated as good for care provided to families, children and young people. The practice is rated as good for the population group of families, children and young people. The premises were suitable for parents with children and babies. Childhood immunisation rates matched the regional average. The GPs worked with the community midwives and health visitors to deliver antenatal and postnatal care. The GP worked with local authority services to safeguard children at risk.

Older people

Good

Updated 8 January 2015

The practice is rated as good for care provided to older people. The practice had a smaller proportion of patients over the age of 60 years compared to the clinical commissioning group (CCG) and national averages. Nationally reported data showed the practice had good outcomes for conditions commonly found amongst older people.  The practice offered proactive, personalised care to meet the needs of the older people in its population and had a range of enhanced services, for example in dementia. The practice was responsive to the needs of older people, including offering home visits and prioritised patients with complex needs. Safeguarding policies and procedures were in place to identify patients at risk of abuse.

Working age people (including those recently retired and students)

Good

Updated 8 January 2015

The practice is rated as good for care provided to working-age people (including those recently retired and students). The practice population had a higher proportion of patients who were working age or recently retired compared to the CCG and national average. The practice had responded to patient feedback by amending the appointment system to allow patients to call in the morning for afternoon appointments. Online services for appointments and repeat prescriptions were offered. A range of health promotion, travel immunisations, health check services and extended surgery were available.

People experiencing poor mental health (including people with dementia)

Good

Updated 8 January 2015

The practice is rated as good for care provided to people experiencing poor mental health (including people with dementia). Data for patients with mental health problems also showed the practice performed better in some areas, for example, dementia diagnosis rate, depression assessment and physical health checks. Eighty six per cent of patients on the practice mental health register had an agreed care plan in place. The practice worked with the community health services to support patients with mental health conditions. There was signposting and information available to patients, on the practice website.

People whose circumstances may make them vulnerable

Good

Updated 8 January 2015

The practice is rated as good for care provided to people whose circumstances may make them vulnerable. The practice had carried out annual health checks for people with learning disabilities and 100% of these patients had received a follow-up. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in and out-of-hours. A priority alert system was used to identify vulnerable patients. The practice provided care to some women who resided in a protective environment. and was sensitive to their care needs