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Inspection Summary


Overall summary & rating

Good

Updated 14 May 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at 70 Norwood Road , also known as Southall Medical Centre, on 8 January 2015. The inspection took place over one day and was undertaken by a Lead inspector, a GP Specialist Advisor and a Practice Manager Specialist Advisor. We looked at care records, spoke with patients, members of the patient participation group (PPG) and staff including the management team.

Overall the practice is rated as ‘Good.’

We found the practice to be good for providing safe, effective, caring, responsive and well led services. It was good for providing services for older people; people with long term conditions; families, children and young people; working age people (including those recently retired and students), people whose circumstances make them vulnerable and people experiencing poor mental health.

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

  • Systems including incident reporting protocols, safeguarding measures and infection control procedures were in place to keep patients safe.

  • Staff were appropriately qualified to deliver effective care and treatment in line with professional guidelines.
  • Patients said that staff were welcoming, caring and treated them with dignity and respect and the GPs involved them in decisions about their treatment and care.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group (PPG). Most patients were satisfied with access to the service and the appointment system. However, some patients fed back that the practice’s opening hours could be improved.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider should:

  • Arrange for the Health Care Assistant to be trained to Level 2 for safeguarding children.

  • Ensure availability of an automated external defibrillator (AED) or undertake a risk assessment if a decision is made to not have an AED on-site.
  • Record the vaccine fridge temperatures for the minimum and maximum temperatures in addition to the actual temperature.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 14 May 2015

The practice is rated as good for providing safe services. Procedures were in place to ensure incidents were reported, analysed and learning shared. Safety alerts received from the NHS central alert system were acted upon however there was no formal arrangement in place for the dissemination and implementation of these. Medicines were managed safely however the practice should record the vaccine fridge temperatures for the minimum and maximum temperatures in addition to the actual temperature. Staff were trained to deal with medical emergencies however, the practice should ensure availability of an automated external defibrillator (AED) or undertake a risk assessment if a decision is made to not have an AED on-site.

Safeguarding procedures were in place to protect children and vulnerable adults from harm. Staff were knowledgeable on safeguarding both children and vulnerable adults and knew who to report to with any concerns. There was a nominated GP safeguarding lead and there were patient registers for vulnerable adults and children. However, the practice should arrange for the Health Care Assistant to be trained to Level 2 for safeguarding children.

Appropriate pre-employment checks had been carried out on staff before they started working for the practice to ensure they were of suitable character.

We observed the premises to be clean and tidy. We saw there were cleaning schedules in place and cleaning records were kept. Patients we spoke with told us they always found the practice clean and had no concerns about cleanliness or infection control.

Systems were in place to monitor risk. Where risks had been identified control measures were in place to minimise them. Equipment used by the practice had undergone regular safety checks.

The practice had a carried out a fire risk assessment to identify actions required to maintain fire safety, fire protection equipment was serviced regularly, nominated staff were trained as fire marshals, fire alarm checks and fire drills had been practiced regularly.

Effective

Good

Updated 14 May 2015

The practice is rated as good for providing effective services. The practice scored positively in their QOF performance and used QOF to steer practice activity

Staff referred to guidance from NICE and used it routinely. People’s needs were assessed and care was planned and delivered in line with current legislation.

The practice had completed clinical audit cycles and we saw evidence of improved outcomes for patients as a result. Staff were suitably qualified to deliver effective care and treatment and the practice worked with other health care professionals to deliver effective care to those patients with more complex needs.

Consent was sought from patients when appropriate and staff had a working knowledge of key legislation such as the Mental Capacity Act 2005.

The practice provided a range of health promotion services and had performed well in areas such as childhood immunisations and cervical screening.

Caring

Good

Updated 14 May 2015

The practice is rated as good for providing caring services.

The results of the national patient survey 2014 showed that 68% of patients described their overall experience of the practice to be ‘good’ and 52% would recommend the practice to someone new to the area which was below the local CCG average of 70%. However the results of the practices’ internal patient satisfaction survey showed that 85% of patients were satisfied with their visit to the practice. We received 23 completed Care Quality Commission patient comment cards and all of these stated that the service was ‘good’, ‘very good’ or ‘excellent.’

Feedback from patients during the inspection was mostly positive about the services they received. Patients told us that staff were caring and treated them with dignity and respect and this was reflected in the CQC comment cards. We also observed this during the inspection and saw that patient confidentiality was maintained.

Responsive

Good

Updated 14 May 2015

The practice is rated as good for providing responsive services.

The practice had planned services to meet the needs of the local population. These included diabetes clinics, extended hours for appointments with the health care assistant on Saturdays and longer appointments for patients who needed them. Most patients were satisfied with access to the service and the appointment system. However, some patients fed back that the practice’s opening hours could be improved.

The practice had recognised the needs of different groups in the planning of its services. For example, bi-lingual staff were recruited to the practice that were able to speak Punjabi and patients also had access to a telephone interpreting service to help them with their communication needs. The practice premises and facilities were accessible for patients with disabilities.

The practice had implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from the Patient Participation Group (PPG) and had a system in place for handling concerns and complaints. Patients’ complaints had been acknowledged and resolved in a timely manner.

Well-led

Good

Updated 14 May 2015

The practice is rated as good for being well-led.

Governance arrangements were in place including policies and procedures to govern activity. Policies and procedures were discussed at practice meetings to embed learning with staff.

There was clear leadership and staff were aware of who they were accountable to and their level of responsibility. Regular meetings were held, staff were supported with training and their performance was monitored through annual appraisals. However the practice did not have a formal vision and strategy in place, although staff we spoke to told us that the practice aims included providing an effective service to patients and being a friendly, approachable practice

The practice proactively gained feedback from staff and patients and acted on it to improve services. The patient participation group (PPG) was active. Staff had received inductions, regular performance reviews and attended staff meetings and events.

Checks on specific services

People with long term conditions

Good

Updated 14 May 2015

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The practice is rated as good for the care of people with long-term conditions.

The practice provided clinics for patients with diabetes, asthma, hypertension and chronic obstructive pulmonary disease (COPD). The practice nurse and health care assistant led clinics for long term conditions and care plans were developed for all patients with long term conditions. All patients with long term conditions were offered annual reviews to check that their health and medication needs were being met in line with best practice. There was a proactive call recall system in place to provide preventative and continuing care for patients. For those people with the most complex needs, the GPs worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people

Good

Updated 14 May 2015

The practice is rated as good for the care of families, children and young people. There were 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. All staff were trained in safeguarding children and were aware of the procedures to follow if they were concerned about a child’s wellbeing and welfare.

Multidisciplinary team meetings were held with GPs, health visitors, social workers and children’s centre staff to discuss and monitor vulnerable children under the age of 5 years of age. The practice provided a range of services for families, babies, children and young people including child development checks and baby and child immunisations. The practice website included a ‘Pregnancy Planner’ which provided patients with comprehensive information on pregnancy, labour, baby care following birth and links to video information on developing birth plans.

The practice used a messaging service which reminded parents when their child’s immunisations were due and follow up telephone calls were made if appointments had not been made. Practice appointments were available outside of school hours and the premises were suitable for children and babies.

Older people

Good

Updated 14 May 2015

The practice is rated as good for the care of older people. Patients over the age of 75 years of age were provided with a named GP and care plans were developed for these patients. Care and treatment was planned with appropriate reviews to meet the identified needs of patients.

There were effective risk assessment processes in place to identify patients at risk of unplanned hospital admission. These patients were reviewed on a regular basis and care plans developed for them.

The practice was responsive to the needs of older people and home visits were provided for patients who were housebound.

The practice worked with other specialists to provide effective care for older patients including end of life care.

Working age people (including those recently retired and students)

Good

Updated 14 May 2015

The practice is rated as good for the population group of working age people (including those recently retired and students).

The needs of the working age population, those recently retired and students had been identified and telephone consultations were available on request and Saturday morning appointments were available with the health care assistant. The practice also used a messaging service which sent patients appointment reminders via text message to mobile telephones. The practice offered health checks, travel vaccinations and health promotion advice.

People experiencing poor mental health (including people with dementia)

Good

Updated 14 May 2015

The practice is rated as good for the care of people experiencing poor mental health.

Call recall systems were in place for mental health reviews and physical health checks for patients. The practice was signed up to the dementia direct enhanced service (DES) to provide an annual health check for people with dementia to improve their health outcomes. Care plans were developed and patients were provided with a named GP.

Staff had received training in dementia care, the mental capacity act and capacity assessments.

The practice worked with other health and social care professionals to ensure a multi-disciplinary approach for care management of people experiencing poor mental health.

People whose circumstances may make them vulnerable

Good

Updated 14 May 2015

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

The practice had a register of patients with learning disabilities and offered annual health checks and longer appointments for them.

An interpreter service was available for patients whose first language was not English.The practice website provided information to explain the role of UK health services, the National Health Service (NHS) and the role of GPs for asylum seekers in 20 various languages. Homeless people were able to register as patients with the practice.

Staff knew how to recognise signs of abuse in vulnerable adults and children and there was a lead GP for safeguarding. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.