Letter from the Chief Inspector of General Practice
Shadbolt Park House Surgery was previously inspected in January 2016 and was rated Good in all domains and overall.
At this inspection in November 2017 the practice is rated as RI overall.
The key questions are rated as:
Are services safe? – Requires Improvement
Are services effective? – Requires Improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Requires Improvement
The practice is rated as requires improvement for providing safe, effective and well led services and; this affects all six population groups:
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 carried out an announced comprehensive inspection at Shadbolt Park House Surgery on 8 November 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
The Health and Social Care Act 2008 states that registered providers must have a registered manager. At the time of the inspection Shadbolt Park House Surgery had no registered manager in post. Registered managers have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. CQC have received confirmation of an application but this is yet to be completed.
At this inspection we found:
- The practice had an open and transparent approach to safety but did not have sufficient effective systems and processes in place to ensure patients were always kept safe. For example, the practice had not completed the required actions after the legionella assessment, a fire risk assessment or fixed wiring testing.
- Staff we spoke with were aware of their responsibilities to raise and report concerns, incidents and near misses. However, during our inspection we found that the practice’s system for recording significant events needed improvement.
- The practice was unable to demonstrate that all staff were up to date with essential training.
- Staff assessed needs and delivered care in line with current evidence based guidance.
- Data from the Quality and Outcomes Framework (QOF) showed the results for practice management of patients with long-term conditions were good.
- Information about services and how to complain was available and easy to understand.
- Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment
- Patients said they were able to book an appointment that suited their needs. Pre-bookable, on the day appointments, home visits and a telephone consultation service were available. Urgent appointments for those with enhanced needs were also provided the same day.
- The practice was equipped to treat patients and meet their needs.
- We observed the premises to be visibly clean and tidy.
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. By establishing more effective and timely ways to record, discuss and learn from significant events.
- Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
- Ensure that care and treatment is provided in a safe way for service users, by conducting the necessary checks required from the Legionella assessment.
- Ensure that premises and equipment used are properly maintained by conducting a fire risk assessment and fixed wire testing (as required every five years).
The areas where the provider should make improvements are:
- Consider ways to identify and support more patients who are carers.
- Review the number of GP appointments offered on a daily basis.
- Where prescriptions are uncollected review if these need to be seen by a GP before being destroyed.
- Strengthen the system for logging and monitoring hand written prescriptions
- Strengthen contingency plans to ensure there are sufficient numbers of staff in order to meet the requirements of the practice.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice