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Stopsley Village Practice Good

Reports


Review carried out on 14 September 2019

During an annual regulatory review

We reviewed the information available to us about Stopsley Village Practice on 14 September 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 25 January 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

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 – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Stopsley Village Practice on 25 January 2018. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether Stopsley Village Practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

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.
  • 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.
  • Appropriate pre-employment checks were in place that included checks of professional registration where relevant.
  • Staff had lead roles within the practice. For example, one of the GPs was the lead for safeguarding and a member of the nursing team was the lead for infection prevention and control.
  • A programme of clinical audit was in place that demonstrated quality improvement.
  • Staff involved and treated patients with compassion, kindness, dignity and respect. Feedback from patients we spoke with and from the CQC comments cards was positive regarding the care received at the practice.
  • Results from the national GP patient survey published in July 2017 were lower than local and national averages in some areas.

The areas where the provider should make improvements are:

  • Continue to review the national GP patient survey results and ensure steps are taken to make improvements where required.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 23 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Stopsley Village Practice on 10 December 2015. Overall the rating for the practice was inadequate (safe and well-led inadequate, effective requires improvement, caring and responsive good) and was placed in special measures for a period of six months.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection carried out on 23 August 2016; overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Staff were aware of their responsibilities to raise concerns and report incidents and near misses.
  • Risks to patients were assessed and well managed. Identified actions from risk assessments had been completed.
  • Audits had been carried out, and we saw evidence that audits were driving improvement in performance to improve patient outcomes.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Staff were supported by appraisals and had personal development plans in place.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice facilities were limited due to the size of the building.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on. The practice had kept staff and patients informed of the outcome of the previous inspection and involved them in making improvements as required.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Implement a system to ensure a review of historical safety alerts is completed.

  • Continue to identify and support patients who have caring responsibilities.

  • Continue to review the facilities available for patients with mobility problems.

  • Keep a record of verbal interactions with patients when dealing with significant events and complaints.

  • Continue to monitor and ensure improvement to national patient survey results, for example, access to the practice via the telephone.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 10 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Stopsley Village Practice on 10 December 2015. Overall the practice is rated as inadequate.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. People received a verbal and written apology when required.
  • Risks to patients were assessed but identified actions were not implemented fully enough, for example, in relation to fire safety and legionella.
  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, there was no recruitment policy and some pre-employment checks were lacking. Essential training had not been completed by all staff members.
  • Data showed patient outcomes were average for the locality.
  • Audits had been carried out, and we saw evidence that audits were driving improvement in performance to improve patient outcomes.
  • The majority of patients said they were treated with compassion, dignity and respect. However, some felt the reception staff were sometimes abrupt when under pressure.
  • Urgent appointments were available on the day they were requested.
  • The practice had sought feedback from patients and had a patient participation group.

The areas where the provider must make improvements are:

  • Develop a process to ensure that patient specific directions (PSDs) are signed by a GP prior to the administration of vaccines by the health care assistant. Implement a cold chain policy to give advice to staff on the processes to follow to maintain the appropriate conditions to transport, store and handle vaccines.
  • Ensure that all staff employed are supported by receiving appraisals and complete the training essential to their roles
  • Review its procedures in relation to safeguarding children and vulnerable adults. In particular staff should receive training appropriate to their role, these patients should be reviewed with the multi-disciplinary team and it should be clear within the practice who is the safeguarding lead.
  • Review infection control procedures including the carrying out of infection control audits and staff training. Establish who is the lead for infection control within the practice and consider the use of audits to ensure good infection control practices continue to take place
  • Implement the actions identified in the risk assessments relating to fire safety and legionella. Complete a risk assessment to determine if a disclosure and barring (DBS) check is required for non-clinical staff performing chaperone duties.
  • Develop a recruitment policy and ensure all necessary employment checks are made for all staff.
  • Improve governance within the practice by identifying and communicating lead roles.

In addition the provider should:

  • Review the access into the building and the facilities available for patients with mobility problems.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The practice will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service.

Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice