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Archived: Dr Mark Webster Good Also known as Frenchwood Surgery

Inspection Summary


Overall summary & rating

Good

Updated 19 June 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Mark Webster also known as Frenchwood surgery on 19 September 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 19 September 2016 inspection can be found by selecting the ‘all reports’ link for Dr Mark Webster on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 11 May 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 19 September 2016.

At this inspection we found that sufficient improvement had been achieved to update the rating for provision of effective and well-led services to good. The practice had addressed the breaches of regulation and was now compliant with all regulations. This report covers our findings in relation to those improvements and also additional findings at this inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

  • The GP was working with a pharmacist from the clinical commissioning group (CCG) medicines management team to improve prescribing trends within the practice.

  • Medication reviews were up to date and reviews for patients with long term conditions were carried out monthly.

  • Consent policy guidance had been developed.

  • Improvements had been made to the clinical audit system. Audits were linked to improvements in patient care.

  • The practice had signed up to the NHS Resilience Programme. This is a system of professional support and mentoring that helps practices to develop and improve.

  • The practice nurse received clinical supervision and met with the GP at the start of her surgery to discuss the patient list.

  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.

  • Patients we spoke with said they were treated with compassion, dignity and respect and felt they were involved in their care and decisions about their treatment.

    However, there were also areas of practice where the provider should make improvements.

    The provider should:

  • Continue to record patient consent in line with the practice consent policy.

  • Discuss clinical based significant events with a GP peer.

  • Continue with efforts to increase the membership of the patient participation group.

  • Continue efforts to improve the uptake of bowel and breast screening for patients.

  • Continue to sustain the improvements made to the overall governance of the practice.

  • Record that a chaperone has been offered even if this is refused.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 9 January 2017

The practice is rated as good for providing safe services.

The practice had made significant improvements since the last inspection

  • There was an improved system in place for reporting and recording significant events, with policy guidance in place for staff

  • Lessons were shared via practice meetings, now documented, to make sure action was taken to improve safety in the practice.

  • When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.

  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.

  • Risks to patients were better assessed and the management of risks was improved

  • Recruitment processes were more comprehensive and staff files were better managed

  • Emergency equipment and protocols for medical emergencies had been introduced.

Effective

Good

Updated 19 June 2017

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework showed patient outcomes were at or above average compared to the national average.

  • Staff were aware of current evidence based guidance.

  • Clinical audits systems had been improved and there was evidence to demonstrate quality improvement.

  • Staff had the skills and knowledge to deliver effective care and treatment.

  • There was evidence of appraisals and personal development plans for all staff.

  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

  • End of life care was coordinated with other services involved.

  • Consent to care and treatment was not consistently recorded in patient records.

  • The offer of a chaperone was not recorded in patient records.

Caring

Good

Updated 9 January 2017

The practice is rated as good for providing caring services.

We saw improvements had been made to ensure the practice delivered a more caring service.

  • Screens had been purchased and were utilised to ensure privacy during examinations

  • Data from the national GP patient survey published July 2016 showed patients rated the practice higher than others for several aspects of care:

    92 .2 % of patients said the GP was good at listening to them compared to the clinical commissioning group (CCG) average of 89% and the national average of 88%. This had improved from 91% from previous results

    90.4% of patients said the GP gave them enough time. This was better than the CCG average of 86% and the national average of 87%, although this had slightly reduced from 92% last year

    94.5% of patients said they had confidence and trust in the last GP they saw, comparable to the CCG average of 95.9% and the national average of 95%. This had reduced from 96% from previous results

  • 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 9 January 2017

The practice is rated as good for providing responsive services.

The practice had made improvements since the last inspection

  • We found the practice had improved communication with Clinical Commissioning Group (CCG) and was reviewing the needs of its local population and engaging with the NHS England Area to secure improvements to services where these were identified.

  • A practice nurse was now employed and was working to improve the management patients with long term conditions. Additional hours were being worked to reduce the back log of patient reviews.

  • An additional Thursday pm clinical session was now available

  • 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.

Information about how to complain was available and easy to understand and evidence showed the practice responded appropriately to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 19 June 2017

The practice is rated as good for being well-led.

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.

  • There was a clear leadership structure and staff felt supported by management. The practice had policies and procedures to govern activity and held regular governance meetings.

  • An overarching governance framework supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.

  • Staff had received inductions, annual performance reviews and attended staff meetings and training opportunities.

  • Reviews of patients with long term conditions had been undertaken to ensure that those patients were called in for regular reviews, support and advice.

  • There was a culture of openness and honesty. The practice had systems for being aware of notifiable safety incidents and sharing the information with staff and ensuring appropriate action was taken.

  • The practice proactively sought feedback from staff and patients and we saw examples where feedback had been acted on. The practice was looking at ways to improve membership of the patient participation group.

  • There was a focus on continuous learning and improvement at all levels.

  • The practice was supported by a pharmacist from the CCG to ensure prescribing was in line with best practice guidelines for safe prescribing.

Checks on specific services

People with long term conditions

Good

Updated 19 June 2017

The provider had resolved the concerns for effective and well-led identified at our inspection on 19 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

The specific findings on these groups can be found by selecting the ‘all reports’ link for Dr Mark Webster on our website at www.cqc.org.uk.

Families, children and young people

Good

Updated 19 June 2017

The provider had resolved the concerns for effective and well-led identified at our inspection on 19 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

The specific findings on these groups can be found by selecting the ‘all reports’ link for Dr Mark Webster on our website at www.cqc.org.uk.

Older people

Good

Updated 19 June 2017

The provider had resolved the concerns for effective and well-led identified at our inspection on 19 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

The specific findings on these groups can be found by selecting the ‘all reports’ link for Dr Mark Webster on our website at www.cqc.org.uk.

Working age people (including those recently retired and students)

Good

Updated 19 June 2017

The provider had resolved the concerns for effective and well-led identified at our inspection on 19 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

The specific findings on these groups can be found by selecting the ‘all reports’ link for Dr Mark Webster on our website at www.cqc.org.uk.

People experiencing poor mental health (including people with dementia)

Good

Updated 19 June 2017

The provider had resolved the concerns for effective and well-led identified at our inspection on 19 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

The specific findings on these groups can be found by selecting the ‘all reports’ link for Dr Mark Webster on our website at www.cqc.org.uk.

People whose circumstances may make them vulnerable

Good

Updated 19 June 2017

The provider had resolved the concerns for effective and well-led identified at our inspection on 19 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

The specific findings on these groups can be found by selecting the ‘all reports’ link for Dr Mark Webster on our website at www.cqc.org.uk.