Archived: The Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Surgery on 23 March 2016. Overall the practice is rated as good.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. However, the practice was not always demonstrating that they were fully investigating events and taking action in response to the learning from these.
• Systems were in place to deal with medical emergencies and staff were trained in basic life support.
• There were systems in place to reduce risks to patient safety. For example, infection control practices were good and there were regular checks on the environment and on equipment used.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Feedback from patients about the care and treatment they received from clinicians was very positive.
• Data showed that outcomes for patients at this practice were similar to outcomes for patients locally and nationally.
• Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Staff felt well supported in their roles and were kept up to date with appropriate training.
• Patients said they were treated with dignity and respect and they were involved in decisions about their care and treatment.
• Patients gave us positive feedback about the appointments system. The majority of patients we spoke with told us they could get through to the practice by phone easily and they could get a routine or urgent appointment when they needed one.
• The practice had good facilities, including disabled access. It was well equipped to treat patients and meet their needs.
• Information about services and how to complain was available but some of this needed updating. The majority of complaints had been investigated and responded to in a timely manner, but we saw a small that required timely investigation and action to prevent re-occurrence. These were linked to significant events.
• There was a clear leadership and staff structure and staff understood their roles and responsibilities.
• The practice provided a range of enhanced services to meet the needs of the local population.
• The practice sought patient views about improvements that could be made to the service. This included the practice having and consulting with a patient participation group (PPG).

The areas where the provider must make improvement are:

• The provider must ensure a robust system is in place for recording, investigating and taking action in response to significant events.

• The provider must make improvements to the complaints process to ensure; patients are provided with accessible and accurate information about how to make a complaint and the various stages of this, all complaints are fully investigated in an appropriately timely manner and action is taken to prevent a re-occurrence.

The areas where the provider should make improvement are:

• Introduce a protocol and guidance for reception staff in dealing with appointment requests.

• Carry out a risk assessment to support the decision not to carry out DBS checks for all staff and review the role of staff that have not had a DBS check as part of this.

• Review the process for referring patients to secondary care for tests or treatments to ensure the referrals are timely.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice