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Inspection Summary


Overall summary & rating

Good

Updated 15 October 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Birchwood Surgery on 15 July 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • 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 there was sometimes difficulty in getting through to the practice by telephone.
  • 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 areas of practice where the provider needs to make improvements.

Importantly the provider should:

  • Carry out regular fire drills.

  • Ensure blank prescriptions are stored securely at all times.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 15 October 2015

The practice is rated as good for providing safe services. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Lessons were learned and communicated widely to support improvement. Information about safety was recorded, monitored, appropriately reviewed and addressed. Risks to patients were assessed and well managed. There were enough staff to keep patients safe. Staff had received appropriate training in relation to safeguarding children and vulnerable adults.

Effective

Good

Updated 15 October 2015

The practice is rated as good for providing effective services. Data showed patient outcomes were comparable to other local and national practices. Staff referred to guidance from the National Institute for Health and Care Excellence and used it routinely. Patients’ needs were assessed and care was planned and delivered in line with current legislation. This included assessing capacity and promoting good health. Staff had received training appropriate to their roles and any further training needs had been identified and appropriate training planned to meet these needs. There was evidence of appraisals and personal development plans for staff. Staff worked with multidisciplinary teams. Clinical audits were carried out to demonstrate quality improvement.

Caring

Good

Updated 15 October 2015

The practice is rated as good for providing caring services. Data showed that patients rated the practice similar to others for several aspects of care. 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 also saw that staff treated patients with kindness and respect, and maintained confidentiality.

Responsive

Good

Updated 15 October 2015

The practice is rated as good for providing responsive services. It reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group (CCG) to secure improvements to services where these were identified.

Patients said urgent appointments were available on the same day. The practice had responded to suggestions from the patient participation group (PPG) to make changes to the premises. 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 that the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 15 October 2015

The practice is rated as good for being well-led. It had a clear vision and strategy. Staff were clear about the vision and their responsibilities in relation to this. There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity. There were systems in place to monitor and improve quality and identify risk. The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group (PPG) was active. Staff had received inductions, regular performance reviews and attended staff meetings and events. Staff were involved in the future planning of the practice.

Checks on specific services

People with long term conditions

Good

Updated 15 October 2015

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. Patients with more than one long term condition had their conditions reviewed in one appointment to avoid multiple visits to the practice. Longer appointments and home visits were available when needed. All these patients had a named GP and a structured annual review to check that their health and medication needs were being met.

Families, children and young people

Good

Updated 15 October 2015

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.

Appointments were available outside of school hours and the premises were suitable for children and babies. The practice had regular meetings with the health visitors.

Older people

Good

Updated 15 October 2015

The practice is rated as good for the care of older people. Nationally reported data showed that outcomes for patients were good for conditions commonly found in 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 and end of life care. The practice provided weekly visits to two local care homes and additional visits as required. It was responsive to the needs of older people, and offered home visits and rapid access appointments for those with enhanced needs.

Working age people (including those recently retired and students)

Good

Updated 15 October 2015

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. Telephone consultations were available. Students at home from university were offered temporary registration if they needed to see a GP. The practice had extended opening hours one evening and one morning a week.

People experiencing poor mental health (including people with dementia)

Good

Updated 15 October 2015

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia). They carried out annual physical health checks and dementia reviews. The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. It carried out advance care planning for patients with dementia. Patients with poor mental health had a named GP.

People whose circumstances may make them vulnerable

Good

Updated 15 October 2015

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. It had carried out annual health checks for people with a learning disability and offered longer appointments. All these patients had a named GP and the practice had a nominated carer’s champion.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. It had told 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.