Archived: Belvoir Vale Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Belvoir Vale Surgery on 20 October 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.
• 95% of patients who completed the national patient survey described their experience of making an appointment as good compared with a CCG average of 73% and a national average of 73%.

• Patients comments cards we reviewed were overwhelmingly positive about the excellent care received by all members of the practice team.

• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy 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 areas of practice where the provider needs to make improvements.

Importantly the provider should

• Ensure CQC registration is up to date and correct in regard to registration of the practice.
• Consider incidents which occur in the dispensary are recorded as significant events when in line with practice policy.
• Put in place a separate policy for the management, testing and investigation of legionella to provide guidance to staff.

• Put a system in place to ensure full clinical audit cycles have been completed.
• Within the Business Continuity Plan ensure mitigating risks and actions are included.
• Embed a system where fridge temperatures in treatment rooms are reset in line with practice policy.
• Ensure that nursing staff who act as a chaperone have received appropriate training.
• Improve the system for the identification of carers and vulnerable patients.
• Have a system in place to ensure that care plans are routinely used for end of life patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice