This practice is rated as required Improvement overall. (Previous inspection February 2015 – Good)
The key questions are rated as:
Are services safe? – Requires Improvement
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Requires Improvement
Are services well-led? – Requires Improvement
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Requires Improvement
People with long-term conditions – Requires Improvement
Families, children and young people – Requires Improvement
Working age people (including those recently retired and students – Requires Improvement
People whose circumstances may make them vulnerable – Requires Improvement
People experiencing poor mental health (including people with dementia) - Requires Improvement
At this inspection we found:
The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However,
assessments to mitigate risks in the absence of Disclosure and Barring Service (DBS) checks had not been carried out.
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.
Data such as QOF exception reporting rates showed areas where exception reporting was above local averages. However, the practice was aware of areas where performance was below local and national averages; and taking steps to improve. For example, improving the uptake of cervical screening, childhood immunisations and maintaining up to date disease registers.
Staff involved and treated patients with compassion, kindness, dignity and respect. Results from the July 2017 national GP patient survey showed that the practice scored above local and national averages in a number of areas. Completed Care Quality Commission comment cards were also positive about the services provided.
Results from the national GP patient survey showed patients did not always find the appointment system easy to use and patients were not always able to access care when they needed it. However, completed CQC comment cards we received during our inspection were more positive.
The practice took action to improve patient satisfaction; however, staff were unable to demonstrate whether actions carried out resulted in improvements in the experience of people accessing the service.
The practice worked with community services to ensure that vulnerable groups in the community were not excluded from accessing quality care. For example, staff worked closely with a local service that provided support for people facing problems with drug and alcohol dependency. Over the past 12 months, 11% of patients engaged in a shared care programme successfully completed a community detox.
There was some focus on continuous learning and improvement at all levels of the organisation. Staff we spoke with verbally described learning from complaints.
In some areas, there were responsibilities, roles and systems of accountability to support governance and management arrangements. However, oversight of systems and processes to manage areas such as safety checks, the identification of trends following incidents; responding to performance issues, monitoring training needs and reducing some risks was not effective.
The areas where the provider must make improvements are:
Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas where the provider should make improvements are:
Continue to review the health and safety risk assessments and areas for improving the building.
Continue exploring measures to improve the uptake of cervical screening and childhood immunisations.
Establish a process for analysing complaints in order to identify trends and continue exploring measures to improve patient satisfaction in areas such as access.
Continue considering reasonable adjustments and arrangements to support patients who may need extra support to access the services, such as patients with physical impairments whilst awaiting relocation.
Review mental health data to ensure clear understanding and reasons for high exception reporting.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice