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Inspection Summary


Overall summary & rating

Good

Updated 26 April 2018

This practice is rated as Good overall. (Previous inspection 11 July 2017 – the practice was rated as Requires improvement.)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Sternhall Lane Surgery on 9 August 2016. The overall rating for the practice was requires improvement. As a result of our findings from this inspection CQC issued a requirement notice for the identified breaches of Regulations 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We carried out a further announced comprehensive inspection on 11 July 2017 to follow up on the breaches of regulations and areas of improvement identified. While most of the issues leading to the breaches in August 2016 had been resolved, further concerns were identified in relation to infection control, medicines management and governance systems. Overall the practice remained rated as requires improvement and CQC issued a requirement notice for the breach of Regulation 17 and a warning notice for the breach of regulation 12.

The full comprehensive reports for the previous inspections in 2016 and 2017 can be found by selecting the ‘all reports’ link for Sternhall Lane Surgery on our website at www.cqc.org.uk.

This inspection was undertaken within six months of the publication of the last inspection as the practice was rated as inadequate for one of the key questions; are services safe? This inspection was an announced comprehensive inspection on 14 March 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was to follow up on the breaches of regulations 12 and 17 and areas of improvement identified from the last inspection, in line with our next phase inspection programme.

At this inspection we found:

  • The practice had clear and improved systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

  • The practice had improved the management of prescriptions and results so they were safe.

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

  • The practice had implemented a number of systems to ensure that staff had the skills and knowledge to provide effective care.

  • Staff involved and treated patients with compassion, kindness, dignity and respect.

  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

  • Complaints were investigated and responded to openly and thoroughly and information about how to make a complaint was easily accessible for patients.

  • There was a positive and open culture and staff felt supported by the practice leaders; systems for cascading information to staff had improved.

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

The areas where the provider should make improvements are:

  • Continue to engage with the premises owner regarding premises improvements.

  • Work to increase the uptake of breast and bowel screening and improve child immunisations in areas that are below the national target.

  • Review how the Patient Participation Group can be used to improve the service delivered.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 26 April 2018

Effective

Good

Updated 26 April 2018

Caring

Good

Updated 26 April 2018

Responsive

Good

Updated 26 April 2018

Well-led

Good

Updated 26 April 2018

Checks on specific services

People with long term conditions

Good

Updated 26 April 2018

Families, children and young people

Good

Updated 26 April 2018

Older people

Good

Updated 26 April 2018

Working age people (including those recently retired and students)

Good

Updated 26 April 2018

People experiencing poor mental health (including people with dementia)

Good

Updated 26 April 2018

People whose circumstances may make them vulnerable

Good

Updated 26 April 2018