During an assessment under our new approach
Date of Assessment: 20 November to 2 December. Hazelwood Group Practice is a GP practice and delivers the service to 10,412 patients under a contract held with NHS England. The National General Practice Profiles states that the ethnic make-up of the practice area is 95% White, 1% Asian, 1% Black, 2% Mixed and 1% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the eighth decile (8 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
SAFE:
The service had a positive learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. However, our review of the clinical system found gaps in medicines that required monitoring such as high-risk medicines that required blood tests.
EFFECTIVE:
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity. However, care was not always based on latest evidence and good practice due to some medicine reviews not being effective
CARING:
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service was working with staff for them to feel better supported in the workplace.
RESPONSIVE:
People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was accessible via various routes and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care. We found the provider had implemented changes to improve access which was reflected in the National GP Patient Survey.
WELL-LED:
The inspection identified gaps in governance, including oversight of high-risk medicine prescribing, inconsistent patient safety alert audits, and underdeveloped quality outcome reviews. Improvements were needed in the management of emergency equipment and infection prevention and control (IPC) practices. The practice was taking proactive action to implement improvements.
Overall, governance arrangements were not ensuring sufficient assurance or driving continuous improvement.