You are here

Inspection Summary


Overall summary & rating

Good

Updated 12 December 2016

Letter from the Chief Inspector of General Practice

During our comprehensive inspection of The Finchampstead Surgery in February 2016 we found a range of concerns. These resulted in the practice being rated as requires improvement for the provision of safe, effective and well led services.

Specifically we found the practice:

  • Did not have appropriate systems in place to ensure the security of prescriptions.

  • Had not completed actions identified in their fire risk assessment.

  • Had not assured themselves that all staff had received relevant immunisations to keep patients and staff safe.

  • Had nationally reported outcomes for patients with long term conditions that were below average. Patients with these conditions may not have been receiving the reviews of their treatment to ensure their care was maintained.

  • Did not keep all policies and procedures relevant to the management and safety of the practice reviewed and up-to-date.

The practice sent us an action plan setting out how the changes they were making to address the issues that led to our concerns.

We carried out a desktop review commencing on 19 October 2016 to ensure these changes had been implemented and that the service was meeting regulations. The ratings for the practice have been updated to reflect our findings. We found the practice had made improvements in effective provision of services since our last inspection on 16 February 2016 and they were meeting the requirements of the regulations in breach.

Specifically the practice had:

  • Introduced stricter controls in monitoring prescriptions and enhanced the security of rooms where blank prescriptions were held.

  • Completed the actions identified in their fire risk assessment.

  • Ensured that staff had received the relevant immunisations to reduce the risk of infection to both patients and other staff.

  • Improved their systems to complete reviews of the care of patients with long term conditions. The practice provided unverified data for the first six months of the recording period in 2016/17. This showed improved outcomes for these patients.

  • Had updated all policies and procedures in accordance with the practice review programme.

We have updated the ratings for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective and well led services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 12 December 2016

The practice is rated as good for providing safe services. Improvements had been made in accordance with the action plan the practice had put in place.

  • The practice ensured that staff received appropriate immunisations to keep patients and colleagues safe. The immunisation status of GPs and nurses was recorded and kept up to date.

  • The practice had improved their processes and systems to keep prescriptions safely stored and secure.

  • Actions required to enhance fire safety had been taken in accordance with the findings of the practice’s fire risk assessment. Fire drills were taking place and the outcomes of such drills recorded.

Effective

Good

Updated 12 December 2016

When we inspected the practice in February 2016, outcome data for patients with long term conditions showed below average performance. The practice had made significant improvement in achieving reviews of treatment and improved outcomes for this group. It is now rated as good for providing effective service.

Examples of improved performance included:

  • 96% of patients diagnosed with a stroke were achieving target blood pressure in the first 6 months of this year’s recording period compared to 69% in 2015/16 (a 27% improvement).

  • 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.

Caring

Good

Updated 21 April 2016

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 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 21 April 2016

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 had secured funds to build an extension which would provide additional consulting and treatment rooms. This would enable the practice to appoint another health care assistant to provide additional appointments for patients.

  • 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 appointment system was kept under weekly review to ensure sufficient appointments were offered and there were clinics held on two evenings every week and three Saturday’s each month. These were helpful for patients who found it difficult to attend during the customary working day.

Well-led

Good

Updated 12 December 2016

When we inspected the practice in February 2016 we found governance systems were operated inconsistently.

The practice had made improvements as set out in their action plan and is rated as good for being well-led.

  • Policies and procedures relevant to the management of the practice were being reviewed in accordance with the practice review timetable. This ensured policies were relevant to the operation of the practice by being kept up-to-date. The dates of the reviews were being recorded.

  • The arrangements to identify, assess and manage risks were being operated appropriately. For example, prescriptions were being stored safely and securely.

  • The systems in place to ensure patients with long term conditions received appropriate health checks and improved outcomes had been reviewed. Data showed significant improvement in uptake of reviews and outcomes for this group in the first six months of the recording period in 2016/17.

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.