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Inspection Summary


Overall summary & rating

Good

Updated 8 December 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Leen View Surgery on 12 April 2016. During that inspection we found that non-clinical staff who undertook chaperone duties had not received a disclosure and barring service (DBS) check, and a risk assessment had not been completed to determine whether this was required.

Also, the recruitment policy did not include reference to all information required by law when recruiting new members of staff. The practice had not obtained assurances that locum doctors who worked there had undergone all required recruitment checks through their employment agency. Effective systems were not in place to oversee and improve some aspects of the quality and safety of the services provided.

Overall the practice was rated as good with are services safe and well-led requiring improvement in view of the above.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Leen View Surgery on our website at www.cqc.org.uk.

After the comprehensive inspection, the practice told us what action they had, and were taking to meet the legal requirement in relation to the breaches.

We undertook a focused inspection on 27 October 2016 to check that the provider had completed the required action, and now met the legal requirements. We visited the practice as part of this inspection.

This report covers our findings in relation to the above requirements.

This inspection found that the provider had taken appropriate action to meet the legal requirements.

  • All staff carrying out chaperone duties had received a disclosure and baring service check. (These checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with vulnerable children or adults).
  • Effective recruitment procedures were followed to ensure the practice obtained the required information and checks prior to new staff working at the practice.
  • A protocol was in place to obtain assurances that locum doctors who work at the practice had undergone required recruitment checks through their employment agency. Two locum doctors files we checked contained copies of the required checks and information.
  • Effective systems were in place to oversee and improve the quality and safety of the services provided, and to reduce risks to patients.    

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 8 December 2016

The practice was rated as good for safe.

  • All staff carrying out chaperone duties had received a disclosure and baring service check. (These checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with vulnerable children or adults).
  • Effective recruitment procedures were followed to ensure the practice obtained the required information and checks prior to new staff working at the practice.

  • A protocol was in place to obtain assurances that locum doctors who work at the practice had undergone all required recruitment checks through their employment agency. Two locum doctors files we checked contained copies of the required checks and information. 

Effective

Good

Updated 10 June 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were generally at or above average compared to the national average. The practice had achieved 97% of available QOF points in 2014/15. The practice’s overall exception rate reporting was 5.2 % which was below the CCG average of 8.9% and national average of9.2%.

  • Staff assessed needs and delivered care in line with current evidence based guidance such as National Institute Clinical Excellence (NICE).

  • A number of clinical audits had been carried out,but these needed strengthening to show improvements in patient care and treatment. Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • There was evidence of appraisals and personal development plans for all staff. The practice had invested in continuous training of its nursing staff, and staff praised the ongoing supervision and support provided.

  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs. Whilst we received assurance regarding this effective work, we found that limited records were kept of meetings held by the practice in respect of multidisciplinary team working.

Caring

Good

Updated 10 June 2016

The practice is rated as good for providing caring services.

  • Data from the national patient survey and other feedback we received rated the practice highly for nurse led care. For example, 90% of patients in the survey said the last nurse they saw was good at involving them in decisions about their care compared to the CCG average of 86% and national average of 85%. Comment cards we received and patients we spoke with on the day also supported this.

  • Data from the national GP patient survey showed patients rated the practice lower than others for some aspects of care. This included 79% of patients said the GP was good at listening to them, compared to the clinical commissioning group (CCG) average of 87% and the national average of 89%. Data also showed that 78% patients considered receptionists at the practice helpful compared to the CCG average of 89% and national average of 87%. Patient feedback from a variety of sources indicated that they felt doctors lacked empathy and understanding and that appointments were rushed.

  • Information for patients about the services were available within the practice. Translation services were available, and often used, for those whose first language was not English.

Responsive

Good

Updated 10 June 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. Extended hours appointments were available for those who could not attend in working hours.

  • Patient satisfaction with opening hours was broadly in line with the national average.

  • The practice had made changes to respond to the increasing demand for patient appointments. This included providing an increase in nursing staff, drop in nurse led clinics (where an advanced appointment was not required) and telephone triage appointments.

  • Access to appointments with a named GP and continuity of care was not always available. For example, 39% of patients in the national patient survey said they usually get to see or speak to their preferred GP compared to the national average of 59%.

  • 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. Evidence showed that the practice responded to issues and concerns raised. Learning from complaints was shared with staff and other stakeholders.

  • The practice had not however undertaken a subsequent evaluation of all complaints received. This would ensure that any learning points, corrected actions and trend analyses had been implemented.

Well-led

Good

Updated 8 December 2016

The practice was rated as good for are services well-led.

  • Effective systems were in place to oversee and improve the quality and safety of the services provided, and to reduce risks to patients.

  • Staff had taken on additional responsibilities and lead roles for specific areas, to ensure the services are effective and to drive continuous improvements.
  • The clinical audit programme had been strengthened to further demonstrate ongoing quality improvement and effective care. 
  • Various policies had been reviewed to ensure they were up-to-date and reflected the procedures followed at the practice. 
  • More regular, structured meetings took place to aid communication and continuously improve how the practice delivered services to patients. 
Checks on specific services

People with long term conditions

Good

Updated 8 December 2016

The practice was rated as requires improvement for safe and well-led at the last inspection. The issues identified affected the ratings of all six population groups.

The practice is rated as good for safe and well-led at this inspection. In view of the improvements all six population groups are rated as good.

Families, children and young people

Good

Updated 8 December 2016

The practice was rated as requires improvement for safe and well-led at the last inspection. The issues identified affected the ratings of all six population groups.

The practice is rated as good for safe and well-led at this inspection. In view of the improvements all six population groups are rated as good.

Older people

Good

Updated 8 December 2016

The practice was rated as requires improvement for safe and well-led at the last inspection. The issues identified affected the ratings of all six population groups.

The practice is rated as good for safe and well-led at this inspection. In view of the improvements all six population groups are rated as good.

Working age people (including those recently retired and students)

Good

Updated 8 December 2016

The practice was rated as requires improvement for safe and well-led at the last inspection. The issues identified affected the ratings of all six population groups.

The practice is rated as good for safe and well-led at this inspection. In view of the improvements all six population groups are rated as good.

People experiencing poor mental health (including people with dementia)

Good

Updated 8 December 2016

The practice was rated as requires improvement for safe and well-led at the last inspection. The issues identified affected the ratings of all six population groups.

The practice is rated as good for safe and well-led at this inspection. In view of the improvements all six population groups are rated as good.

People whose circumstances may make them vulnerable

Good

Updated 8 December 2016

The practice was rated as requires improvement for safe and well-led at the last inspection. The issues identified affected the ratings of all six population groups.

The practice is rated as good for safe and well-led at this inspection. In view of the improvements all six population groups are rated as good.