5 January 2017
During a routine inspection
Letter from the Chief Inspector of General Practice
On 18 May 2016 we carried out an announced comprehensive inspection at Whitburn Surgery. The overall rating for the practice was requires improvement, having being judged as requires improvement for Effective and Well Led and inadequate for Safe The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Whitburn Surgery on our website at www.cqc.org.uk.
Following the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:
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Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe care and treatment.
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Regulation 15 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Premises and equipment.
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Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance.
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Regulation 18 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Staffing.
This announced comprehensive inspection was carried out on the 5 January 2017 in order to review the action by the practice to be compliant with the regulations. Overall the practice is now rated as good.
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Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses; improvements had been made to the significant event reporting process.
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Risks to patients were assessed and well managed.
- 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.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
- The practice had a system in place for handling complaints and concerns and responded quickly to any complaints.
- Patients we spoke with raised no concerns regarding making an appointment.
- The practice had good facilities and was well equipped to treat patients and meet their needs.
- There was a 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 regulation.
The areas where the provider should make improvements are:
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Develop an effective system for clinical audit.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice