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Inspection Summary


Overall summary & rating

Good

Updated 7 September 2016

Letter from the Chief Inspector of General Practice

We carried out a focused inspection of Victor Street Surgery on 29 July 2016 to check that action had been taken since our previous inspection in April 2015. Overall the practice is rated as good. The practice was good for Effective, Caring, Responsive and Well Led services.

However we found that the practice required improvement in the Safe domain due to breaches of regulations relating to safe delivery of services.

We found that the practice had not ensured recruitment arrangements included all necessary employment checks for all staff. There were no fire and legionella risk assessments. Safeguarding, basic life support and fire safety training needed to be undertaken for relevant staff. The medicine/vaccination refrigerators required servicing and calibration. Prescriptions were not kept securely and only accessible to authorised people and the practice required effective infection prevention and control systems.

We inspected the practice on 29 July 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection of Victor Street Surgery on our website at www.cqc.org.uk

Our key findings for this inspection were as follows:

The provider had made improvements:

  • Action plans had been produced following infection control audits.
  • The practice reviewed its water safety risk assessment in relation to Legionella to ensure that the water supply did not pose a risk to patients, visitors or staff.
  • Recruitment arrangements included all necessary employment checks for all staff had been carried out.
  • Safeguarding, basic life support and fire safety training had been undertaken by relevant staff.
  • New medicine/vaccine refrigerators had been purchased.

The practice is now rated good for Safe services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 7 September 2016

The practice is rated as good for providing safe services.

  • Risks to patients were assessed and well managed.
  • Action plans had been produced following infection control audits.

  • Water safety risk assessment in relation to Legionella to ensure that the water supply did not pose a risk to patients, visitors or staff had been completed.

  • Recruitment arrangements included all necessary employment checks for all staff had been carried out.

  • Safeguarding, basic life support and fire safety training had been undertaken by relevant staff.

  • New medicine/vaccine refrigerators had been purchased.

Effective

Good

Updated 27 August 2015

The practice is rated as good for providing effective services. Data showed patient outcomes were at or above average for the locality. 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. Not all staff had received training appropriate to their roles.

Caring

Good

Updated 27 August 2015

The practice is rated as good for providing caring services. Data showed that patients rated the practice higher than other GPs both locally and nationally 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 27 August 2015

The practice is rated as good for providing responsive services. It reviewed the needs of its local population and engaged with the 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 27 August 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 and held regular governance meetings. There were some systems in place to monitor and improve quality. The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group (PPG) was active. Staff had received inductions, performance reviews and attended staff meetings and events.

Checks on specific services

People with long term conditions

Good

Updated 27 August 2015

The practice is rated as good for the care of people with long term conditions.

The practice held a number of nurse led clinics to support patients with long term conditions such as diabetes, coronary heart disease, asthma and chronic obstructive pulmonary disease. GPs supported patients with care plans that they regularly reviewed. Care plans also formed part of the practice’s hospital admissions avoidance. Complex Care meetings were held which reviewed hospital admissions and assessed whether admission could have been avoided and whether staff could have done anything differently. Notes of these meetings were made within patient notes as part of the review process. Minutes of the complex care meeting were taken and circulated to all GPs, district nurses, community nurses, over 75s nurse to ensure those not in attendance at the meeting were aware of discussions and subsequent actions.

Families, children and young people

Good

Updated 27 August 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 Accident and Emergency attendances. Appointments were available outside of school hours and the premises were suitable for children and babies. Emergency processes were in place and referrals were made for children and pregnant women whose health deteriorated suddenly. Weekly family planning, antenatal and baby clinics were also available. We saw examples of joint working with midwives, health visitors and school nurses.

Older people

Good

Updated 27 August 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. It was responsive to the needs of older people, and offered home visits and rapid access appointments for those with enhanced needs. All of the patients over 75 had a named GP. Staff were able to recognise signs of abuse in older people and knew how to escalate or refer these concerns. The practice had a good working relationship with local community services and district nurses were based at the practice. Discussions took take place regularly between the district nurses and GPs. Monthly Multi-Disciplinary Team Meeting (complex care) were held which where attended by GPs, district nurses, community matrons and the over 75’s nurse.

Working age people (including those recently retired and students)

Good

Updated 27 August 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. Access to GP advice was provided through telephone consultations as well as face to face appointments. There was an online booking system which enabled patients to book, change and cancel appointments and request repeat prescriptions without the need to visit or telephone the practice. NHS health checks were available for those aged between 40 and 74 and extended hours were available from 7.30am on four weekday mornings, until 8.00pm one weekday evening and one Saturday morning a month.

People experiencing poor mental health (including people with dementia)

Good

Updated 27 August 2015

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

The practice achieved good outcomes in relation to meeting the needs of patients with mental health needs. The practice kept a register of these patients which they used to ensure they received relevant checks and tests. Where appropriate, a comprehensive care plan had been completed for patients who were on the register. Care plans were written and agreed with patients and their carers. The practice hosted in house weekly counselling sessions and worked with multi-disciplinary teams to help meet the needs of patients experiencing poor mental health. For example, primary care mental health team counselling services.

People whose circumstances may make them vulnerable

Good

Updated 27 August 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 offered annual health checks for patients with a learning disability and 70% of these patients had taken this up. It also offered longer appointments for patients with a learning disability.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. Staff sign-posted vulnerable patients to various support groups and voluntary organisations. Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff had undertaken training on domestic abuse and sexual violence and 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.