Archived: All Saints and Rosevillas Medical Practice

Letter from the Chief Inspector of General Practice

This was a desk-based focussed review of All Saints and Rosevillas Medical Practice carried out on 16 March 2017. During our previous inspection on 19 January 2016 we found that the practice performance related to the care of people experiencing poor mental health (including people with dementia) was significantly lower than the local Clinical Commissioning Group (CCG) and National averages. After this desk-top review we found the practice had made improvements for this population group. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for All Saints and Rosevillas Medical Practice on our website at www.cqc.org.uk.

• The practice was rated as requires improvement for the population group ‘People experiencing poor mental health (including people with dementia)’

This inspection was a desk-based review carried out on 16 March 2017 to confirm that the practice had implemented its plan to improve its performance in meeting the care needs of people experiencing poor mental health (including people with dementia). This report covers our findings in relation to those requirements and also additional improvements made since our last inspection

Our key findings were as follows:

• The practice performance for the care and treatment of patients experiencing poor mental health (including patients with dementia) had improved over the past two years. The practice had put systems in place to ensure ongoing improvements and monitoring of its performance.

During our previous inspection in January 2016, we found that there were areas that the practice should make improvements. For this review the practice provided information to demonstrate the action they had, and were continuing to take to address these areas. This included:

• At the inspection in January we found that a Legionella risk assessment had been carried out but the practice had not acted on the recommendations made in the assessment report, which included the need to flush taps and check water temperatures to monitor and control the risk of legionella. Information provided by the practice manager for this desk-top review showed that the practice had addressed these concerns. Information and documents we received showed that the practice had worked with a health and safety team and had repeated a legionella risk assessment. The outcome showed that the level of risk at the practice was low and appropriate health and safety risk assessments were in place to ensure the safety of patients, visitors and staff. The cleaning company used by the practice flushed the water system within the practice, and reported any problems to the practice manager. A named group of staff were responsible for recording the water temperatures. These staff carried out these tasks on a rota basis to ensure that the monitoring continued during annual leave or staff sickness. Staff had also received training to ensure that they knew how to use the equipment and record accurate data. This data was recorded on a monthly basis to ensure the safety of staff, visits and patients.

• At the inspection in January 2016 we found some gaps in training for both clinical and non-clinical staff. A staff training matrix showed that some staff had received training in basic life support, infection control, fire safety and safeguarding. Information we received for the desktop review showed that

To improve communication with all staff a practice wide meeting was introduced every first Thursday of the month. This included, administration staff, reception staff, practice nurses, healthcare assistant and GPs. Guest speakers were also invited to attend these meetings. An example of the minutes for meeting held in 2017 showed that the topics discussed included operational changes at both sites, significant events, infection prevention, health & safety, complaints and the training needs of staff.

• During our previous inspection in January 2016, we found that the practice had plans in place to encourage more structured and regular feedback from patients. This included actively advertising and encouraging patients to form a patient participation group (PPG) to work with the practice and be involved in its future plans for development. Information provided by the practice for this review showed that progress had been made to encourage patients to be involved in the running of the practice. The practice manager and one of the GP partners told us that although the PPG had been slow to build and gain momentum, meetings had been held. Five patients had attended the last PPG meeting. The practice found that patients were reluctant to take on the responsibility of chairing the meetings but were keen to listen and make comments and suggestions. Minutes of these meetings were completed and copies were seen for meetings held in May 2016 and January 2017. The practice was looking at other ways to encourage the growth of the PPG, which included an open day to showcase the work of the PPG.

There were areas of practice where the provider should make improvements:

• Ensure that records are up to date to accurately demonstrate all relevant training undertaken by all staff.

At our previous inspection on 19 January 2016, we rated the practice as requires improvement for the care of people experiencing poor mental health (including people with dementia). The practice had acted on the concerns and as a consequence ratings for the practice in this population group has been updated to reflect our most recent findings. The practice is now rated as good for this population group.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice