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The Finchampstead Surgery Good

Inspection Summary


Overall summary & rating

Good

Updated 9 August 2019

We carried out an announced focused inspection at Finchampstead Surgery on 14 June 2019. This inspection was carried out due to the commission receiving information of concern. This report covers our findings in relation to those concerns.

The full comprehensive report on the previous inspections can be found by selecting the ‘all reports’ link for Finchampstead Surgery on our website at .

The practice is rated as good overall. We did not rate the practice following this focused inspection.

Our key findings were as follows:

  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • Staff worked together and with other organisations to deliver effective care and treatment.

However, the provider should:

  • Ensure all patients with a Do Not Attempt Cardio-pulmonary Resuscitation order in place have an initial assessment fully documented.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Effective

Good

Caring

Good

Responsive

Good

Well-led

Good
Checks on specific services

People with long term conditions

Good

Updated 12 December 2016

When we inspected the practice in February 2016 we judged the practice required improvement for provision of safe, effective and well led services. This affected all population groups. The practice had made significant improvements. These have led to a new rating of good for this population group.

  • Improvements in operating safe systems were demonstrated. Fire risks were managed, staff immunisations were being monitored and prescriptions were held securely.

  • Policies and protocols were being kept under review and the reviews were being recorded. This ensured policies were relevant to delivery of services to patients.

Outcomes and the take up of annual health checks had improved for this group of patients including:

  • 88% of patients diagnosed with diabetes had already received a foot examination compared to 85% in the whole of the previous year.

  • 90% of patients diagnosed with diabetes had achieved target cholesterol levels in the last six months compared to 74% in the previous year.

  • 90% of patients diagnosed with COPD (a type of lung disease) had their care reviewed in the first six months of 2016/17 which matched the 90% achieved in the full year 2015/16.

From our previous inspection we also found the practice:

  • Nursing staff took lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

  • Offered longer appointments and home visits to this group of patients when needed.

Families, children and young people

Good

Updated 12 December 2016

When we inspected the practice in February 2016 we judged the practice required improvement for provision of safe, effective and well led services. This affected all population groups. The practice had made significant improvements. These have led to a new rating of good for this population group.

  • Improvements in operating safe systems were demonstrated. Fire risks were managed, staff immunisations were being monitored and prescriptions were held securely.

  • Policies and protocols were being kept under review and the reviews were being recorded. This ensured policies were relevant to delivery of services to patients.

  • 86% of eligible patients attended for cervical cancer screening in the last three years. This was better than both the clinical commissioning group (CCG) average of 84% and national average of 81%.

From our previous inspection we also found the practice:

  • Had systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.

  • Treated children and young patients in an age-appropriate way.

  • Offered appointments outside of school hours and the premises were suitable for children and babies.

  • Worked positively with midwives and health visitors.

Older people

Good

Updated 12 December 2016

When we inspected the practice in February 2016 we judged the practice required improvement for provision of safe, effective and well led services. This affected all population groups. The practice had made significant improvements. These have led to a new rating of good for this population group.

  • Improvements in operating safe systems were demonstrated. Fire risks were managed, staff immunisations were being monitored and prescriptions were held safely.

  • Policies and protocols were being kept under review and the reviews were being recorded. This ensured policies were relevant to delivery of services to patients.

From our previous inspection we also found the practice:

  • Was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

  • Offered proactive, personalised care to meet the needs of the older people in its population.

Working age people (including those recently retired and students)

Good

Updated 12 December 2016

When we inspected the practice in February 2016 we judged the practice required improvement for provision of safe, effective and well led services. This affected all population groups. The practice had made significant improvements. These have led to a new rating of good for this population group.

  • Improvements in operating safe systems were demonstrated. Fire risks were managed, staff immunisations were being monitored and prescriptions were held securely.

  • Policies and protocols were being kept under review and the reviews were being recorded. This ensured policies were relevant to delivery of services to patients

From our previous inspection we also found the practice:

  • Was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

  • Offered extended hours clinics and telephone consultations to benefit patients who found it difficult to attend during the working day.

People experiencing poor mental health (including people with dementia)

Good

Updated 12 December 2016

When we inspected the practice in February 2016 we judged the practice required improvement for provision of safe, effective and well led services. This affected all population groups. The practice had made significant improvements. These have led to a new rating of good for this population group.

  • Improvements in operating safe systems were demonstrated. Fire risks were managed, staff immunisations were being monitored and prescriptions were held securely.

  • Policies and protocols were being kept under review and the reviews were being recorded. This ensured policies were relevant to delivery of services to patients.

Outcomes and the take up of annual health checks had improved for this group of patients including:

  • 91% of patients diagnosed with dementia had a face to face review of their care in the last six months which was an 18% improvement on the 73% achieved in 2015/16.

From our previous inspection we also found the practice:

  • Regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.

  • Carried out advance care planning for patients with dementia.

  • Told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

  • Had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

  • Ensured staff had a good understanding of how to support patients with mental health needs and dementia.

People whose circumstances may make them vulnerable

Good

Updated 12 December 2016

When we inspected the practice in February 2016 we judged the practice required improvement for provision of safe, effective and well led services. This affected all population groups. The practice had made significant improvements. These have led to a new rating of good for this population group.

  • Improvements in operating safe systems were demonstrated. Fire risks were managed, staff immunisations were being monitored and prescriptions were held securely.

  • Policies and protocols were being kept under review and the reviews were being recorded. This ensured policies were relevant to delivery of services to patients.

From our previous inspection we also found the practice:

  • Identified patients with caring responsibilities and offered them support and advice. These patients were signposted to support groups and benefits advice.

  • Held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.

  • Offered longer appointments for patients with a learning disability.

  • Regularly worked with other health care professionals in the case management of vulnerable patients.