Tudor Lodge Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Tudor Lodge Surgery on 11 February 2015. Overall the practice is rated as requires improvement.

Specifically we found it good for effective, caring and responsive services. It was also good for providing services for older people, people with long-term conditions, mothers, babies, children and young people, working-age population and those recently retired, people in vulnerable circumstances who may have poor access to primary care and people experiencing poor mental health. It required improvement for providing safe services and for being well led.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• Risks to patients were assessed and well managed, with the exception of those relating to staff recruitment checks and aspects of building safety.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• 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.
• Patients said the practice had much improved the ability to make an appointment with a named GP and that 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.
• 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.

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

Importantly, the provider must:

• Ensure that the risks to patients, staff and visitors such as fire safety, infection control are risk assessed and actions put in place to mitigate those risks.
• Ensure that criminal records checks through the Disclosure and Barring Service (DBS) on these staff or any of the others that have joined the practice since January 2013 including the practice manager are undertaken

In addition the provider should:

• Ensure there are planned and recorded processes for regular meetings and decision making at the practice for significant events, safeguarding, and discussions about patient care.
• Ensure there is a system of monitoring that patient safety alerts were read and actioned, where appropriate, by staff.
• Ensure that records relating to staff training are maintained and up to date.
• Ensure that Patient Group Directions (PGDs) the written instructions for the supply or administration of medicines such as vaccines are signed for by the GP responsible before implementation.
• Ensure there is a system of tracking blank prescription printer paper through the practice when distributed to printers in consulting and treatment rooms.
• Ensure there are records kept of audits, checks and the monitoring of the quality of the service such as those for infection control, health and safety and cleaning.
• Ensure there is a system of management, testing and investigation of legionella (a bacterium that can grow in contaminated water and can be potentially fatal).
• Ensure that staff annual appraisals occurred.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice