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Inspection Summary


Overall summary & rating

Good

Updated 17 January 2017

Letter from the Chief Inspector of General Practice

We carried out an announced follow up inspection at The Lennard Surgery on 15 December 2016 to check if improvements had been made in response to our previous comprehensive inspection on 29 September 2015.

On 29 September 2015 we found the practice required improvement in the safe domain and was rated by us as good for effective, caring, responsive and well-led domains. Overall the practice was rated as good. We issued a requirement notice with regards to the breach of Regulation 19 of the Health and Social Care Act (Regulated Activity) Regulations 2014, Fit and proper persons employed:

  • The requirement notice was for the provider to make improvements to ensure recruitment arrangements included all necessary employment checks for all staff. During our inspection we saw personnel employed to carry on the regulated activity did not have the appropriate checks through the Disclosure and Barring Service or risk assessments to identify they were not required. The practice did not hold the required specified information in respect of persons employed by the practice as listed in Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

In addition we told the provider they should:

  • Evidence that action plans were implemented and completed to rectify concerns found during infection control audits.
  • Have a system of recording comments / verbal complaints made to the service for audit purposes.
  • Continue to develop a system of clinical audits and re-audits to improve patient outcomes.
  • Have a risk assessment and policy for the management, testing and investigation of legionella (a bacterium which can contaminate water systems in buildings).

A copy of the report detailing our findings can be found at www.cqc.org.uk.

Our key findings across the areas we inspected on 15 December 2016 were as follows:

  • There was a system to ensure appropriate recruitment checks had been undertaken prior to employment. For example, proof of identification, references, qualifications, registration with the appropriate professional body and the appropriate checks through the Disclosure and Barring Service.
  • Infection prevention and control systems for healthcare-associated infection were in place.
  • The practice assessed, planned and effectively managed potential risks to the service from fire.
  • The practice monitored patient care and treatment outcomes through clinical audits and re-audits.
  • There was a system to record and respond to patient verbal complaints and concerns.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 17 January 2017

The practice is now rated as good for providing safe services. We found the provider had taken actions to provide a safe service following our comprehensive inspection of the practice on 29 September 2015. This included reliable systems, processes and practices in place to support safe recruitment practices including disclosure and barring checks being carried out on all staff with personal contact with patients.

Effective

Good

Updated 7 January 2016

The practice is rated as good for providing effective services.

  • Data showed patient outcomes were at or above average for the locality.

  • Staff assessed needs and delivered care in line with current evidence based guidance.

  • The practice should develop a system of clinical audits and re-audits to improve patient outcomes.

  • Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • There was evidence of appraisals and personal development plans for all staff.

  • Staff worked with multidisciplinary teams to understand and meet the range and complexity of people’s needs.

Caring

Good

Updated 7 January 2016

The practice is rated as good for providing caring services.

  • Data showed that patients rated the practice higher than 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 7 January 2016

The practice is rated as good for providing responsive services.

  • The practice reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.

  • 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.

  • 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 7 January 2016

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 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 and held regular governance meetings.

  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. There were gaps in these arrangements to monitor and improve quality and identify risk in infection control and the prevention of risk of legionella.

  • The provider was aware of and complied with the requirements of the Duty of Candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for knowing about notifiable safety incidents

  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.

  • There was a strong focus on continuous learning and improvement at all levels.

Checks on specific services

People with long term conditions

Good

Updated 7 January 2016

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 similar to the CCG and better than national average. For example the percentage of the patients on the diabetes register, with a record of a foot examination and risk classification within the preceding 12 months was 92.06% with the national average 88.35%.

  • 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 medicines needs were being met. For those people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people

Good

Updated 7 January 2016

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.

  • The practice’s uptake for the cervical screening programme was 84.27%, which was better than the national average of 76.9%.

  • Appointments were available outside of school hours and the premises were suitable for children and babies.

  • We saw good examples of joint working with midwives, health visitors and school nurses.

Older people

Good

Updated 7 January 2016

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. Care plans were in place for those identified at greater risk.

Working age people (including those recently retired and students)

Good

Updated 7 January 2016

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 7 January 2016

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

  • Performance for mental health related indicators was better to the national average. For example the percentage of patients with recognised/diagnosed disorder who had a comprehensive, agreed care plan documented in their records in the preceding 12 months was 88.37%, the national average was 86.04%

  • The percentage of patients diagnosed with dementia whose care had been reviewed in a face to face review in the preceding 12 months was 84.91% which was comparable to the CCG and national average of 83.82%.

  • 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.

  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

  • It 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 people with mental health needs and dementia.

People whose circumstances may make them vulnerable

Good

Updated 7 January 2016

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 homeless people, travellers and those with a learning disability.

  • The practice offered longer appointments for people with a learning disability.

  • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable patients.

  • The practice 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.