25 August 2016
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
In February 2016 a comprehensive inspection of Victoria Cross Surgery was conducted. The practice was rated as requires improvement for safe, effective and well led, and good for caring and responsive. Overall the practice was rated as requires improvement. During that inspection we found concerns related to: the investigation and actions following significant events; the recording of discussions and actions during practice meetings; the training for safeguarding children and adults; the child protection register; the security of blank prescriptions; recruitment checks; the system of clinical audit; the mandatory training and appraisals; the governance arrangements for infection control; fire safety arrangements; and legionella risk assessment.
We advised the practice they should: improve the cervical screening uptake and smoking cessation advice uptake; develop and implement a clear action plan to improve the outcomes for learning disabilities patients and patients experiencing poor mental health; and ensure that complaints information is updated.
The report setting out the findings of the inspection was published in March 2016. Following the inspection we asked the practice to provide an action plan detailing how they would improve on the areas of concern.
We visited the practice and carried out an announced focused inspection of Victoria Cross Surgery on 25 August 2016 to ensure the changes the practice told us they would make had been implemented and to apply an updated rating.
We found the practice had made significant improvement since our last inspection on 10 February 2016. At the inspection undertaken in February 2016 we rated the practice as requires improvement for providing safe, effective and well led services. For this reason we have only rated the location for the key questions to which this related. The practice is now rated as good for providing safe, effective and well led services. This report should be read in conjunction with the full inspection report of 10 February 2016.
At this inspection we found:
- Risks to patients were assessed and managed.
- Systems were in place to monitor the outcomes for patients.
- Recruitment and training records were up to date and monitored.
- Significant events were investigated and any actions undertaken and learning shared.
The areas where the practice should make improvements are:
- Ensure an on-going system including audits to monitor and improve outcomes for patients.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice