Archived: 80 Tettenhall Road Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at 80 Tettenhall Road Surgery on 18 May 2015. Overall the practice is rated as good.

Specifically, we found the practice to require improvement for providing safe services. We found the practice to be good for providing effective, caring, responsive and well-led services. It was found to be good for providing services for older people; people with long-term conditions; families, children and young people; working age people; people whose circumstances may make them vulnerable and people experiencing poor mental health.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• 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.
• Most patients said they found it easy to make an appointment. Urgent appointments were available within 48 hours. On the day appointments were available for children and vulnerable adults.
• There was a clear leadership structure and staff felt supported by the management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw one area of outstanding practice:

• There was a system in place to ensure that vulnerable adults received appropriate care and treatment. The practice maintained a list of 11 vulnerable adults and reception staff actively recorded when they were seen. Reception staff telephoned these patients each month if they had not visited the practice, to enquire about their health and wellbeing. Where appropriate, appointments were made for these patients to be seen by the GP.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must:

• Ensure that appropriate staff have been subject to, or been risk assessed for the need to have a Disclosure and Barring Service check carried out. They should also put in place a system to monitor that the practice nurse’s professional registration is in date to ensure they are fit to carry out their role.

In addition the provider should:

• Put measures in place, such as installing a switchless socket or clearly labelling the vaccine fridge plug with a cautionary notice, to prevent the accidental interruption of the electricity supply to the vaccine fridge.
• Ensure fire drills are carried out regularly to ensure that staff are aware of how to safely evacuate patients in the event of a fire. An oxygen warning sign should be fitted to the door of the room where the oxygen cylinder is stored to alert the fire service to its presence in the event of a fire.
• Ensure there is a system in place to review and update policies and procedures in a timely manner.
• Ensure that risk assessments are completed and an action plan put in place to manage all identified risks.
• Ensure that the facilities in place to support patients with mobility disabilities are fit for purpose and meet their needs.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice