We carried out a review of the data available to us about Faccini House Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Faccini House Surgery, you can give feedback on this service.
We carried out this announced comprehensive inspection at Faccini House Surgery on 29 January 2019. We had previously carried out an announced comprehensive inspection on 23 November 2017. At that time the service was rated as requires improvement. It was rated as requires improvement for the safe, effective and well led domains and good for caring and responsive.
The areas where we said that the provider must make improvement were:
We based our judgement of the quality of care at this service on a combination of:
At this inspection we found that the practice had addressed all of the issued from the previous inspection, and have rated this practice as good overall and good for all population groups.
We found that:
Whilst we found no breaches of regulations, the provider should:
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
This practice is rated as requires improvement overall. (The practice was previously inspected on 13 January 2015 and was rated as good overall.)
The key questions are rated as:
Are services safe? – good
Are services effective? – requires improvement
Are services caring? – requires improvement
Are services responsive? – requires improvement
Are services well-led? - requires improvement
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – requires improvement
People with long-term conditions – requires improvement
Families, children and young people – requires improvement
Working age people (including those retired and students – requires improvement
People whose circumstances may make them vulnerable – requires improvement
People experiencing poor mental health (including people with dementia) - requires improvement
We undertook an announced comprehensive inspection of Faccini House Surgery on 23 November 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was carried out in line with our next phase inspection programme but also in response to information sharing from the General Medical Council and concerns from monitoring information we review about the practice.
At this inspection we found:
There was no clear process for acting on safety and medicines alerts.
The practice did not have adequate assurance that one of the nurse practitioners who had been working alone during Saturday morning clinics had indemnity cover and up to date basic life support training appropriate to their role. The practice resolved these issues following the inspection.
Care and treatment was not monitored effectively enough for people with long-term conditions and mental health conditions.
The practice did not hold structured clinical meetings. This limited opportunities for clinical staff to share best practice, discuss clinical risks and provide peer support.
Staff told us that they treated patients with compassion, kindness, dignity and respect and involved patients in decisions about their care. However national GP patient survey data indicated that patient satisfaction with care shown during consultations was low.
Although the practice had tried to improve appointment availability, patients found it difficult to contact the practice by telephone and they reported that they were not able to easily see their preferred GP.
Patients had difficulty getting an appointment on the day.
Complaints were investigated and responded to openly and thoroughly, however information about how to make a complaint was not easily accessible for patients.
The practice had recently worked with the Patient Participation Group (PPG) to gather patient views. However systems for engaging with patients and acting on concerns were not well-established.
The practice had a some well-managed systems in place to keep people safe and reduce risk so that safety incidents were less like to happen.
There was a positive and open culture and staff felt supported by the practice leaders.
The areas where the provider must make improvements as they are in breach of regulations are:
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care with regards to: clinical governance, risk management and monitoring care and treatment for people with long-term conditions and mental health conditions.
The areas where the provider should make improvements are:
Review and improve uptake for immunisations and screening programmes.
Improve patient satisfaction with care and treatment and access to the service.
Make information about how to make a complaint or raise concerns readily available to patients and the public.
Review practice policies and procedures so the duty of candour is clearly reflected.
Improve systems for engaging with patients, obtaining patient feedback and acting on concerns.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Faccini House Surgery on 13 January 2015. Overall the practice is rated as good.
Specifically, we found the practice to be good for providing safe, well-led, effective, caring and responsive services. It was also good for providing services for all the population groups including older people; people with long term conditions; mothers, babies, children and young people; the working age populations and those recently retired; people in vulnerable circumstances and people experiencing poor mental health.
Our key findings across all the areas we inspected were as follows:
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain were available and easy to understand.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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.
Chief Inspector of General Practice