We carried out an announced comprehensive inspection at Fieldhead Surgery on 18 and 19 October 2022. Following this inspection, we rated the location as good overall, and for all key questions:
Safe - Good
Effective - Good
Caring – Good
Responsive – Good
Well-led - Good
Why we carried out this inspection
This announced comprehensive inspection was carried out due to a change in the provider for this service. This was the first rated inspection since this change.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting some staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A shorter site visit.
- Reviewing staff questionnaires.
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We have rated this practice as good overall.
We found that:
- There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
- Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
- There was a programme of quality improvement activity, including clinical audit.
- Staff had the skills, knowledge and experience to deliver effective care.
- Staff involved and treated people with compassion, kindness, dignity and respect.
- The National GP Patient Survey scores were below the local and national averages in some areas, and other sources of feedback had indicated difficulties with access. We saw the practice had undertaken additional surveys of a larger sample of patients who had contacted the practice by telephone or attended the practice for an appointment. The outcome of the surveys demonstrated improvement. The practice was also monitoring access through their telephone analytics system.
- Leaders demonstrated they had the capacity and skills to deliver high-quality, sustainable care.
Whilst we found no breaches of regulations, the provider should:
- Formalise the system for summarising new patient medical records.
- Continue to monitor and make improvements to increase the uptake of cervical screening.
- Improve the identification of carers on the practice register.
- Continue to monitor patient outcomes for access, in particular accessing the practice by telephone and the experience of making an appointment.
- Continue with the drive to recruit and form a Patient Participation Group representative of the practice population.
The evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services