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Inspection Summary


Overall summary & rating

Good

Updated 17 July 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Beeches Green Surgery on 24 November 2016. The overall rating for the practice was requires improvement because breaches of regulation relating to the safe and well led provision of services were identified. The full comprehensive report on the 24 November 2016 inspection can be found by selecting the ‘all reports’ link for Beeches Green Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 20 June 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 24 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 ensured that identified risks relating to infection control and fire safety had been actioned and managed.
  • All recommended training had been undertaken by staff.
  • Policies had been reviewed and updated relating to chaperone duties.
  • Learning from significant events were being shared to drive improvement in a timely manner.
  • The practice had focussed on improved collaborative working with the patient participation group.

The area where the provider should improve:

  • Review systems and processes to encourage carers to attend for an annual health check.



Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 17 July 2017

At the last comprehensive inspection on the 24 November 2016, we found the practice was not meeting legal requirements for providing safe services. Since our last inspection, the practice had made a number of improvements to address the breaches in regulations we previously identified.

Specifically:

  • We saw that incidents raised as significant events were now discussed regularly at practice meetings and learning and any changes to practice were clearly documented
  • The infection control policy had been updated, the lead nurse had been appointed as the infection control lead. Actions from the infection control audit had been completed and the practice had improved oversight and monitoring of the cleaning team employed by NHS property services.
  • Actions identified in the practice fire risk assessment had been addressed. There were still difficulties in ensuring that the landlords NHS property services fulfilled their responsibilities. To resolve this the practice had referred the situation to the fire and rescue services. The practice staff had undertaken fire drills.
  • The practices chaperone policy had been updated and we saw evidence that this had been discussed at a practice meeting.

Effective

Good

Updated 26 January 2017

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was evidence of appraisals and personal development plans for all staff.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 26 January 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for some 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 26 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 to secure improvements to services where these were identified. For example 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 an alternative local centre when necessary.
  • 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.
  • The practice provided medical services to two residential units for people with eating disorders The practice provided general medical care, wound care in instances of self-harm and psychiatric support when necessary.
  • The practice provided cognitive behaviour therapy (CBT- a talking therapy that can help manage problems by changing the way people think and behave) for their patients.
  • The practice provided an audiology service for their patients. We saw evidence that this had significantly reduced the number of referrals to secondary care, and had in the last twelve months identified six potentially serious cases that were referred for further care in a timely way. Patients were appreciative of the service which provided prompt care close to home.

Well-led

Good

Updated 17 July 2017

At the last comprehensive inspection on the 24 November 2016, we found the practice was not meeting legal requirements for providing safe services. Since our last inspection, the practice had made a number of improvements. Specifically we found:

  • Governance and performance management was operating effectively in relation to infection control, fire safety and learning from significant events
  • All recommended training had been undertaken by staff.
  • The practice had worked with the clinical commissioning group to improve effective working with the patient participation group and plans were in place to take this forward.
  • We saw that the practice had improved the identification of carers however there had been no improvement in the numbers of carers receiving a health review.

Checks on specific services

People with long term conditions

Good

Updated 17 July 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 24 November 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 17 July 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 24 November 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 17 July 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 24 November 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 17 July 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 24 November 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 17 July 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 24 November 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 17 July 2017

The provider had resolved the concerns for safety and well-led identified at our inspection on 24 November which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.