This practice is rated as Good overall. (Previous inspection October 2016 – Good with safe domain 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
We carried out an announced comprehensive inspection at Billesdon surgery on 26th April 2018 following up on previous breaches of regulations found in 2016.
In October 2016 the practice was issued with a requirement notice for the breach of regulation 12 for Safe care and treatment of the Health and Social care act. The regulation was not being met as the registered person did not do all that was reasonably practicable to assess, monitor, manage and mitigate risks to health and safety of service users. The practice needed to make improvements in systems to manage medications and review the repeat prescribing procedure for high risk medications.
At this inspection we found:
The practice had addressed all concerns that were identified at the previous inspection.
- The practice had clear systems to manage risk so that safety incidents were less likely to happen.
- 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.
- There was an emphasis on continuous learning and improvement at all levels of the practice. This included the significant event analysis, sharing and updating of policies, clinical audit and feedback from patients and staff.
- The practice implemented and monitored changes to ensure the patients’ needs were always met.
- 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.
- There were named accountable clinicians for areas of the practice and also non-clinical lead for patients with dementia or carers.
- The leadership structure was well embedded within the practice.
The areas where the provider should make improvements are:
- Review the process to ensure all safety alerts are received, recorded and acted upon.
- Review any missed appointments for children or vulnerable adults within secondary care documenting the response in all cases and act upon if required.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice