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Inspection Summary


Overall summary & rating

Good

Updated 6 January 2017

Letter from the Chief Inspector of General Practice

The practice was inspected on 16 August 2016. The inspection was a comprehensive inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (HSCA). At that inspection, the practice was rated ‘good’ overall. However, within the key questions safe and well-led, areas were identified as requires improvement, as the practice was not meeting the legislation at that time; Regulation 17 Good governance.

At the inspection in August 2016 we found that systems and processes in place to manage staff training had not been sufficient to ensure all staff had received safeguarding training appropriate for their role.

There were insufficient systems and processes in place to ensure all clinical staff had appropriate medical indemnity cover in place.

The practice supplied an action plan and a range of documents which demonstrated they are now meeting the requirements of Regulation 17 Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas

Safe

Good

Updated 6 January 2017

The practice is rated as good for providing safe services.

In line with agreed timescales the practice supplied a range of documentary evidence to demonstrate how they had improved their practices in relation to good governance since the inspection carried out in August 2016.

Evidence supplied included copies of risk assessments and evidence to demonstrate all clinical staff had indemnity insurance in place. A Legionella risk assessment had been conducted and information safety sheets had been obtained for all substances used within the practice.

Effective

Good

Updated 6 January 2017

The practice is rated as good for providing effective services.

This rating was given following the comprehensive inspection in August 2016. A copy of the full report following this inspection is available on our website http://www.cqc.org.uk/search/services/doctors-gps

Caring

Good

Updated 6 January 2017

The practice is rated as good for providing caring services.

This rating was given following the comprehensive inspection in August 2016. A copy of the full report following this inspection is available on our website http://www.cqc.org.uk/search/services/doctors-gps

Responsive

Good

Updated 6 January 2017

The practice is rated as good for providing responsive services.

This rating was given following the comprehensive inspection in August 2016. A copy of the full report following this inspection is available on our website http://www.cqc.org.uk/search/services/doctors-gps

Well-led

Good

Updated 6 January 2017

The practice is rated as good for providing well-led services.

In line with agreed timescales the practice supplied a range of documentary evidence to demonstrate how they had improved their practices in relation to good governance since the inspection carried out in August 2016.

Evidence supplied included copies of training records to demonstrate that clinical staff had achieved child safeguarding training to level 3. There was evidence to show that clinicians had all completed safeguarding adults training.

Checks on specific services

People with long term conditions

Good

Updated 6 January 2017

The practice is rated as good for the care of people with long term conditions.

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
  • Performance for diabetes related indicators was either higher than or in line with the local and national averages.
  • Diabetic patients were referred to training courses to encourage them to self-manage their condition.
  • Longer appointments and home visits were available when needed.
  • All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
  • The practice had supported a member of the reception team to train as a phlebotomist so blood samples could be taken in house.

Families, children and young people

Good

Updated 6 January 2017

The practice is rated as good for the care of families, children and young people.

  • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances.
  • Immunisation rates were relatively high for all standard childhood immunisations.
  • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.

Older people

Good

Updated 6 January 2017

The practice is rated as good for the care of older people.

  • The practice offered proactive, personalised care to meet the needs of the older people in its population.
  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
  • The practice offered annual health checks to those patients over the age of 75.

Working age people (including those recently retired and students)

Good

Updated 6 January 2017

The practice is rated as good for the care of working age people (including those recently retired and students).

  • The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

People experiencing poor mental health (including people with dementia)

Good

Updated 6 January 2017

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
  • The practice carried out advance care planning for patients with dementia.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
  • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
  • Staff had a good understanding of how to support patients with mental health needs and dementia.
  • One of the GPs carried out ‘virtual’ ward rounds twice a year to review the needs of patients resident in a local specialist hospital for patients experiencing difficulties with their mental health. All of these patients were registered at the practice.

People whose circumstances may make them vulnerable

Good

Updated 6 January 2017

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
  • The practice offered longer appointments for patients with a learning disability.
  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.
  • The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
  • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.