Archived: Eastholme Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Eastholme Surgery on 9 November 2016. Overall the practice is rated as good.

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

• The practice had moved location within the last nine months from an older property to a nearby new modern facility. This had created a few challenges both in the logistics before and after the move. However, the staff team confirmed they now felt more settled.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• 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.
• Personalised patient centred care reflecting the different needs of patient population groups was evident in all aspects of the practice’s work.
• The practice provided both urgent and pre-booked appointments each day. The practice manager monitored patient demand to ensure all those who requested an urgent appointment were either seen or spoken to by a GP.
• 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.
• 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.
• Evidence was available that demonstrated the practice complied with the Duty of Candour requirement.

The areas where the provider should make improvement are:

• Improve the quality of recording meeting minutes to clearly identify the issues discussed, the actions agreed and to provide a template to monitor and review progress.
• Undertake the planned Disclosure and Barring Service (DBS) checks for all staff undertaking the role of chaperone.
• Obtain references for locum GPs used at the practice.
• Develop a policy and protocol for responding to medical emergencies to support the staff’s existing knowledge.
• Develop and implement a plan for continued quality improvement and clinical audit.
• Continue to promote, develop and facilitate a patient reference group to include patients who do not have access or skills to use IT.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice