Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Ashfield House - Annesley Woodhouse on 10 March 2015. Overall the practice is rated as requires improvement.
Specifically, we found the practice inadequate for providing safe services, and required improvement for providing effective and well led services. It was good for providing a caring and responsive service.
It was inadequate for providing services for people whose circumstances may make them vulnerable and required improvement for providing care to the other five population groups we inspected as a result of the findings in the five domains which applied to all population groups.
Our key findings across all the areas we inspected were as follows:
- Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, safeguarding systems in place were not robust enough and appropriate recruitment checks on staff had not been undertaken prior to their employment.
- Risks to patients were not fully assessed and well managed. For example actions identified to address concerns with infection control, and health and safety practices had not been appropriately reviewed and addressed.
- Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
However, we found limited assurance to demonstrate shared learning from complaints, incidents and significant events amongst all staff.
- Patients’ needs were assessed and care was planned and delivered following best practice guidance.
- Some clinical audits had been carried out but we saw limited evidence to demonstrate that audits were completed cycles and driving improvements in performance to improve patient outcomes.
- The practice had a number of policies and procedures to govern activity, but these needed reviewing.
- The practice had limited governance arrangements to ensure that risks were identified, assessed and managed effectively. Staff feedback had not been proactively sought to secure improvements in the service.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
- Patients said they generally found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
- The practice had proactively sought feedback from patients and had an active patient participation group (PPG).
The areas where the provider must make improvements are:
- Ensure systems for assessing and monitoring the quality and safety of service provision are effective by; carrying out completed clinical audit cycles, including for minor surgery in order to monitor the quality and safety of services and to drive improvements in patient care.
- Ensure there are formal governance arrangements in place with evidence to demonstrate these are effective and staff are aware how these operate.
- Ensure there are mechanisms in place to seek feedback from staff to enable the provider to form an opinion about the quality of the services provided.
- Ensure there are effective systems in place to ensure risks to patients, staff and visitors are identified, assessed and managed appropriately. This includes the following areas; safeguarding, significant event investigation and analysis, infection control, fire safety and health and safety checks.
- Ensure there are effective policies in respect of recruitment. This includes ensuring that all staff records contain information and documentation to demonstrate that staff are suitable to work with patients before they start working at the practice.
- Ensure up to date records are kept in respect of the management of regulated activities. This includes ensuring there are appropriate policies, procedures and guidance available to all staff to support them in carrying out their role.
In addition the provider should:
- Improve processes for making appointments and availability of non-urgent appointments.
- Review the system in place for complaints handling and investigation to ensure the most appropriately qualified member of staff undertakes the investigation and analysis of the information.
On the basis of the ratings given to this practice at this inspection, we will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will place them into special measures
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice