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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 19 June 2017

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 19 June 2017

Responsive

Good

Updated 19 June 2017

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.