30 November 2017
During a routine inspection
Letter from the Chief Inspector of General Practice
This practice is rated as requires improvement overall.
At our previous comprehensive inspection of 14 December 2015 the practice was rated as good overall, with requires improvement for the domain of safe and good for the domains of effective, caring, responsive and well-led.
This inspection was an announced inspection carried out on 30 November 2017. This was to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 14 December 2015. W e inspected this service as part of our comprehensive inspection programme.
At our inspection of 30 November 2017, the key questions are rated as:
Are services safe? – Requires improvement
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires improvement
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Requires improvement
People with long-term conditions – Requires improvement
Families, children and young people – Requires improvement
Working age people (including those recently 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
The population groups are rated requires improvement overall because t here are aspects of the practice that require improvement which therefore has an impact on all population groups. There were, however, examples of good practice.
At this inspection we found:
-
Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses.
-
Outcomes for patients who use services were good.
- Patients’ needs were assessed and care was planned and delivered following best practice guidance.
-
Staff were consistent and proactive in supporting patients to live healthier lives through a targeted approach to health promotion. Information was provided to patients to help them understand the care and treatment available.
-
Staff involved and treated patients with compassion, kindness, dignity and respect.
-
Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
- There was a clear leadership structure in place and staff felt supported by management. The practice sought feedback from staff and patients, which they acted on.
- The practice was aware of and complied with the requirements of the duty of candour.
The areas where the provider must make improvements as they are in breach of regulations are (See Requirement Notice Section at the end of this report for further detail);
-
Ensure care and treatment is provided in a safe way to patients.
The areas where the provider should make improvements are:
- Ensure persons employed in the provision of the regulated activity receive the appropriate appraisal necessary to enable them to carry out the duties.
-
Risk assess the need to have a paediatric pulse oximeter.
-
Carry out regular fire drills.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice