Archived: Dr. S.J. Godfrey & Partners

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr SJ Godfrey and Partners on 19 July 2016. Overall the practice is rated as good. Our key findings across all the areas we inspected were as follows:

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Reviews and investigation had taken place when needed. We found learning was not consistently recorded as being shared with relevant members of staff. At the time of the inspection learning points had been noted, but there were no details of ongoing monitoring of actions taken to maintain patient safety.

• Risks to patients were assessed and managed. There was an open and transparent approach safety and systems in place for reporting and recording significant events. However at the time of inspection the documentation was not always clear regarding the cascade to staff.

• 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. However not all action was taken as to whether the patient was satisfied with the response received , best practice suggests that efforts are made to ensure a complainant is fully satisfied with the response to their concerns.

• Following the inspection the provider informed us of changes they had made to their systems to ensure information was cascaded to relevant staff.  

• Data showed patient outcomes were comparable to the national average. We saw evidence that audits were driving improvements to patient outcomes.

• Information about services was available; patients who wished to have information leaflets in their own language could request this from the administration staff.

• 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.

• 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.

• The practice had a number of policies and procedures to govern activity. However there was not a clear version control and several versions of the same policy were available to staff. Other policies had in some cases overlapping information. The practice were in the process of uploading all current policies onto their computer system.

• 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 provider was aware of and complied with the requirements of the duty of candour. 

The areas where the provider must make improvements are:

• Review recording arrangements of staff training to demonstrate that safeguarding adults training has been delivered.
• Continue to review arrangements to ensure that learning points and actions from significant are consistently documented and shared with all staff and actions are monitored.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice