Letter from the Chief Inspector of General Practice
This practice is rated as Good overall. However we rated the practice as Requires Improvement for providing well led services. A previous inspection, carried out on 21 April 2015 rated the practice as good overall, with the safe domain rated as requires improvement. A breach of regulation was identified on that occasion. A focused follow up inspection carried out on 4 April 2016 found the practice had carried out the necessary improvements; and the safe domain was rated as good.
The key questions are rated as:
Are services safe? – Good
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 – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
We carried out an announced comprehensive inspection at Lister Lane Surgery on 28 March 2018 as part of our inspection programme.
At this inspection we found:
- The practice had a system for reporting and taking action on significant events. The practice did not retain summary details of significant events, noting actions taken or lessons learned. This meant that learning to help prevent the recurrence of incidents was not always assured.
- The practice had a number of policies and protocols in place in relation to staff activity. However we saw that these were not always appropriately updated, and that updated policies were not always available to all staff, particularly those based at branch sites.
- The process for receiving, disseminating and acting upon Medicines and Health Regulatory Agency (MHRA) and other patient safety alerts was not demonstrable by recorded actions.
- Quality improvement activity, in relation to prescribing, referral and minor surgical procedures was carried out. The practice benchmarked against a number of local practices in relation to accident and emergency attendances and unplanned admissions.
- The practice had systems for dealing with complaints in line with national timescale requirements. We saw that written communication did not contain Parliamentary and Health Service Ombudsman details.
- The practice hosted diabetic retinal eye screening and musculoskeletal (MSK) services. This enabled them to access summary record details pertaining to secondary care for patients.
- Patients were able to access services at any one of three sites operated by the practice. The premises’ facilities were appropriate to meet the needs of patients.
- We observed patients being treated with compassion and respect. Patient feedback we received, both in person and on CQC comment cards provided examples of caring and responsive care being provided by the practice.
- Some patients told us access to the practice by telephone was difficult. The practice told us they were aware of the issue, and had plans in place to improve this.
- At the time of our visit the registration details held by the Care Quality Commission were not up to date. The practice told us they were in the process of addressing these.
The areas where the provider must make improvements as they are in breach of regulations are:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The areas where the provider should make improvements are:
- Establish systems for reviewing the immunisation status of staff, in line with the Department of Health’s guidance.
- Liaise with the landlord with responsibility for their Boothtown branch site to assure themselves that health and safety assessments and processes are completed in a timely manner.
- Review and improve the means by which patients using disabled toilet facilities at the Nursery Lane site are able to alert staff in the event of an accident.
- Comply with infection prevention and control requirements by ensuring sharps bins are appropriately situated, signed and dated at all times, and that all equipment is in date.
- Continue to review and risk assess stocks of emergency medicines and equipment to ensure it is adequate to meet patients’ needs.
- Include the Parliamentary and Health Services Ombudsman details on all written communications in relation to patient complaints.
- Review and improve systems for identifying and supporting patients acting in an unpaid caring role.
- Continue to encourage and educate their patient population to attend appointments with national cancer screening programmes.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice