Archived: Queenswood Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Queenswood Surgery on 6 September 2016. Overall the practice is rated as Requires Improvement.

Our key findings across all the areas we inspected were as follows:

• The arrangements for governance and performance management were not always embedded or operated effectively. There is limited assurance that risks to patients were assessed and well managed. For example, those relating to management of legionella, blank prescription stationery security, safeguarding training, fire safety and lack of records of electrical equipment testing checks.There was limited oversight of the system managing access for patients with limited mobility.
• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment, but not all staff had received an appraisal of their performance within the last year.
• 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 was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns. The practice had gathered feedback from patients through the Patient Participation Group.
• Patients said they found it easy to make an appointment with a named GP and 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.
• 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 provider was aware of and complied with the requirements of the duty of candour.
• The practice collaborated with other practices as part of the local Vanguard multi-speciality project to provide alternative routes for patients who require home visits.
• The practice had identified over 4% of the patient population who were also carers and provided them with appropriate support.

The areas where the provider must make improvement are:

• Ensure that governance and systems for health and safety are operated effectively and any risks are appriopriately managed. For example, management of legionella and electrical equipment testing checks.

The areas where the provider should make improvement are:

• The provider should review the use of family members as translators for patients whose first language is not English.
• All policies should be regularly reviewed to ensure they reflect current processes in the practice.
• The provider should continue to review the access arrangements to meet the needs of all patients. 

• The provider should review the system for managing the security of prescription stationery.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice