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Inspection Summary


Overall summary & rating

Good

Updated 21 April 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kingsholm Surgery on 7 November 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Kingsholm Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 28 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 7 November 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

Our key findings were as follows:

  • The practice had reviewed and updated their fire procedures. A fire risk assessment and subsequent actions and recommendations had been carried out.

  • The practice had reviewed and updated their procedures for checking and maintaining emergency equipment, and medicines, and had implemented a log to check these regularly.

  • The practice had reviewed their Disclosure and Barring Service (DBS) procedure to ensure that all staff who undertook chaperoning duties had received a DBS check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

  • The practice had updated their training matrix to ensure that all outstanding training had been undertaken by all staff.

  • All staff that had been in post for a minimum of 12 months had received an annual appraisal.

During our previous inspection we also highlighted areas where the practice should consider improvement and these had improved as follows:

  • The practice had ensured that safety alerts were logged with actions taken recorded.

  • The practice continued to monitor and improve outcomes for patients with long term conditions.

  • The practice was improving their identification of carers.

  • The practice had established a patient participation group for engaging with their patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 21 April 2017

When we inspected the practice in November 2016 we identified a breach of regulation leading to a rating of requires improvement. The practice had undertaken improvements since the last inspection and at this inspection we found they were complying with regulations. They are now rated good for the provision of safe services. Specifically we found:

  • Fire procedures had been updated and a fire risk assessment had been completed.

  • Emergency equipment and medicines procedures had been updated and a log to check these regularly was in place.

  • Disclosure and Barring Service (DBS) procedures had been updated in relation to staff who undertook chaperoning duties. All staff who chaperoned and new starters that may chaperone, were DBS checked. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

During our previous inspection we also highlighted areas where the practice should consider improvement and these had improved as follows:

  • The practice had ensured that safety alerts were logged, with actions taken recorded. A standing agenda item for safety alert discussions had been added to staff meetings.

Effective

Good

Updated 21 April 2017

When we inspected the practice in November 2016 we identified a breach of regulation leading to a rating of requires improvement. The practice had undertaken improvements since the last inspection and at this inspection we found they were complying with regulations. They are now rated good for the provision of effective services. Specifically we found:

  • Relevant staff had now completed their required mandatory training.

  • An on-going appraisal plan had been implemented and all staff had received an appraisal.

During our previous inspection we also highlighted areas where the practice should consider improvement and these had improved as follows:

  • The practice continued to monitor and improve outcomes for patients with long term conditions. The practice had recruited an advanced nurse practitioner and implemented a high blood pressure protocol in line with new guidelines. The practice implemented a recall service for over 75’s who did not present with chronic illness or on an annual medication review and implemented a system to call and assess all patients over 50yrs discharged from A & E within 48 working hours of receiving the discharge notes.

  • The practice were improving their identification of carers by displaying a carers statement in the waiting room, asking all new patients if they were or had a carer and updating their new patient registration questionnaire to identify if patients were carers.

Caring

Good

Updated 10 January 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice others 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 saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Good

Updated 10 January 2017

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and clinical commissioning group (CCG) to secure improvements to services where these were identified. For example, the CCG pharmacist visited the practice once a week as part of a prescribing initiative plan to reduce antibiotic prescribing.

  • The practice participated in a CCG led initiative called Choice Plus which allowed additional emergency slots to be available for patients to be seen at either Gloucester Health Access Centre or Matson Lane Surgery. The appointments were triaged at the practice and available under strict criteria, this resulted in greater emergency appointment availability for patients of the practice.

  • The practice participated in a local social prescribing initiative whereby patients with non-medical issues, such as financial debt or social isolation could be referred by a GP to a single hub for assessment as to which alternative service might be of most benefit and could be seen at the practice.

  • The practice provided a regular GP visiting service and urgent care to a local care home and nursing home. A named GP or deputy visited fortnightly to provide a “ward round review” and assess all new residents on admission.

  • Patients said they found it easy to make an appointment with a named GP and 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 the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 21 April 2017

When we inspected the practice in November 2016 we identified breaches of regulation leading to a rating of requires improvement. The practice had undertaken improvements since the last inspection and at this inspection we found they were complying with regulations. They are now rated good for the provision of well led services. Specifically we found:

  • The practice had developed and implemented new procedures to ensure that governance arrangements were in place in relation to fire safety, training, appraisals, management of emergency procedures and management of chaperoning procedures.

During our previous inspection we also highlighted areas where the practice should consider improvement and these had improved as follows:

  • The practice had established a patient participation group (PPG) and had recruited 12 patients as members. The practice was awaiting responses from prospective PPG members to ascertain a date for the initial PPG meeting.
Checks on specific services

People with long term conditions

Good

Updated 21 April 2017

The provider had resolved the concerns for safety, effectiveness and well-led identified at our inspection on 7 November 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Families, children and young people

Good

Updated 21 April 2017

The provider had resolved the concerns for safety, effectiveness and well-led identified at our inspection on 7 November 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Older people

Good

Updated 21 April 2017

The provider had resolved the concerns for safety, effectiveness and well-led identified at our inspection on 7 November 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

Working age people (including those recently retired and students)

Good

Updated 21 April 2017

The provider had resolved the concerns for safety, effectiveness and well-led identified at our inspection on 7 November 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People experiencing poor mental health (including people with dementia)

Good

Updated 21 April 2017

The provider had resolved the concerns for safety, effectiveness and well-led identified at our inspection on 7 November 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

People whose circumstances may make them vulnerable

Good

Updated 21 April 2017

The provider had resolved the concerns for safety, effectiveness and well-led identified at our inspection on 7 November 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.