Archived: All Saints Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at All Saints Practice on 28 November 2016. The overall rating for the practice was Inadequate and the practice was placed in special measures for a period of six months.

Some of the issues found were;

• There was no formal system in place for managing patient safety alerts.

• There were no arrangements in place to assure the safe management of medicines such as vaccines are followed in accordance with practice’s cold chain policy.

• The practice did not ensure that significant events were investigated thoroughly and recorded in accordance with the practice’s significant event policy.

• Risks to patients were not always assessed and well managed; the practice did not risk assess the absence of certain emergency medicines for e.g. GTN spray/ tablets.

The full comprehensive report on the 28 November 2016 inspection can be found by selecting the ‘all reports’ link for All Saints Practice on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 1 September 2017. Overall the practice is now rated as Requires Improvement.

Our key findings were as follows:

• Staff understood their responsibility to formally report incidents, near misses and concerns; we saw evidence that significant events were recorded and investigated in a timely way, discussed at clinical and practice meetings and learning was shared.

• The practice had a number of policies and procedures to govern activity, for example there was a cold chain policy, which had set escalations as a significant event including to the provider for the Hurley Clinical Partnership and NHS England.

• Risks to patients were assessed and well managed.

• There was a system in place for highlighting, monitoring and cascading patient safety alerts; however staff were not always aware of current evidence based guidance, such as NICE.

• Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.

• Patients informed us that they were treated with compassion, dignity and respect. However they stated that the lack of enough GPs made it difficult to feel involved in decisions about their care and treatment, as well as finding it difficult to make appointments.

• Information about services and how to complain was available and easy to understand.

• The practice offered early morning and late evening appointment to meet the needs of the local population. Patients were also able to make appointments online.

• 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.

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

Importantly, the provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care, in particular in relation to NICE guidelines

• Continue to develop an ongoing programme that demonstrates continuous quality improvements to patient care in a range of clinical areas. This may include clinical audit.

• Although the results are improving the practice should continue to assess, monitor and improve the access to and satisfaction with appointments in view of the low patient survey results.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice