Archived: Fort House Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Fort House surgery on 26 January 2016. Breaches of legal requirements were found during that inspection within the safe domain. The practice was rated as good overall, requires improvement in the safe domain and good in the effective, caring, responsive and well-led domains. After the comprehensive inspection, the practice sent to us an action plan detailing what they would do to meet the legal requirements. We undertook a focused inspection on 08 November 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. The provider was now meeting all requirements and was rated as good overall and good under the safe domain. This report only covers our findings in relation to those requirements.

During the previous inspection on 26 January 2016 we found that the areas where the practice must make improvements were:

• To ensure all fire safety equipment is regularly serviced and that it is clarified to fire marshals what their responsibilities are. Ensure that all actions identified following fire risk assessments are implemented.

• To ensure that a Legionella risk assessment is carried out.

This report should be read in conjunction with the last report from 26 January 2016. The report from our last comprehensive inspection can be read by selecting the 'all reports' link on our website at www.cqc.org.uk.

During this inspection we found that:

• The practice had had all fire equipment checked by a specialist company. The fire marshals were clear about their roles. A further fire risk assessment had been carried out and the findings implemented.

• A Legionella risk assessment had been carried out and acted on.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Fort House Surgery on 26 January 2016. Overall the practice is rated as good.

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

• 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 the skills, knowledge and experience to deliver effective care and treatment.
• 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.
• 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.
• There was a strong culture of team work and pulling together, throughout the whole practice.
• The practice were innovative and constantly looking to improve the services that they could offer their patients.
• The practice employed an external company to risk assess the practice on a quarterly basis.
• Risks to patients were assessed and well managed with the exception of fire safety and Legionella.
• 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.

We saw one area of outstanding practice:

In response to a patient participation group (PPG) survey and subsequent audit work by an external organisation in 2013, the practice had completely overhauled its appointments system. Despite the practice patient numbers increasing by nearly 3000 patients in the last three years and no facility to extend the building, they had maintained satisfaction scores consistently above average in the national GP patient survey with regard to access to appointments.

The areas where the provider must make improvement are:

Ensure all fire safety equipment is regularly serviced and that it is clarified to fire marshals what their responsibilities are. Ensure that all actions identified following fire risk assessments are implemented.

Ensure that a Legionella risk assessment is carried out.

The areas where the provider should make improvement are:

Review how and where emergency medicines are stored.

Ensure that all samples are stored in a dedicated sample fridge.

To ensure all policies are reviewed regularly and that the reviews are signed and dated and old versions removed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice