17 June 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out this comprehensive inspection on 17 June 2015.
Overall, we rated this practice as good.
Specifically, we found the practice to require improvement for providing safe services. The practice was good for providing effective, caring and responsive services, and for being well led.
Our key findings were as follows:
- Staff generally understood the process to report incidents, and there was some evidence of learning and discussion around incidents. However not all incidents were fully recorded, and learning was not shared widely. Staff awareness of incidents varied, and we could not always verify whether actions had been taken as a result of an incident.
- Risk assessments relating to the safe running of the practice were not always monitored and reviewed.
- The practice provided a good standard of care, led by current best practice guidelines. Care and outcomes for patients was not always audited fully.
- Patients told us they were treated with dignity and respect.
- Patients could access generally appointments without difficulty, and were happy with the telephone and repeat prescribing systems.
- The building had sufficient facilities and equipment to provide effective services.
- The practice had some strategy and objectives for the future, however staff awareness of these varied.
We saw some areas of outstanding practice including:
- Once a month the practice held awareness days for carers to enable them to keep up-to-date with help and advice. The practice worked with a local carer support organisation who held open days within the practice on a quarterly basis.
- The practice had a buddy system to allow patients who may struggle to access some areas of the service to have one point of contact with a named member of staff, who would assist them with tasks such as making an appointment or ordering medication.
However, there were also areas of practice where the provider needs to make improvements.
Importantly the provider must:
- Ensure systems are in place to assess, monitor and mitigate the risks to patients, staff and visitors to the practice.
The provider should:
• Ensure that ‘patients at risk’ registers are regularly reviewed and updated.
• Ensure that learning from incident and complaints is fully recorded and cascaded to maximise learning opportunities.
• Ensure that formal governance arrangements are sufficient to fully assess and monitor risks and the quality of the service provision.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice