02/02/2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Dr A G Kippax and Dr A M Statham on 02/02/2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
- The practice was experiencing a challenging period of time due to the long term absence of one of the GP partners. However, a strong and supportive team ethos was evident as staff worked together and flexibly to overcome this challenge.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
- Risks to patients were assessed and well managed.
- While we saw that significant events were reported and recorded, the records lacked detail and not all significant events were documented as such. This resulted in learning opportunities not being maximised and made it difficult for the practice to identify and monitor any trends accurately.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Patient feedback was very positive about the care received.
- Information about services and how to complain was available and easy to understand.
- Patients said they 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 good facilities and was well equipped to treat patients and meet their needs.
- Although the practice’s leadership capacity was reduced at the time of inspection, 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.
The areas where the provider should make improvements are:
-
Consider the threshold for reporting, recording, acting on and monitoring significant events, incidents and near misses and improve thematic analysis of these. Ensure investigations into all significant events are thorough and records detail sufficient information in order to maximise learning opportunities.
-
Ensure thorough pre-employment recruitment checks are embedded into the practice recruitment process.
-
Ensure complaint handling processes fully reflect current guidance.
-
Audits should be repeated in order to fully complete the audit cycle and ensure that any changes to practice continue to result in improvements to patient outcomes.
-
Consider whether additional locum sessions would be beneficial to reduce pressures during periods of GP partner absence.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice