Letter from the Chief Inspector of General Practice
Narrowcliff Surgery was inspected on Tuesday 10 March 2015. This was a comprehensive inspection.
Overall the practice is rated as good.
Specifically, we found the practice to be good for providing effective, caring and responsive services. It was also good for well led and providing services for the six population groups. It required improvement for providing safe services.
Our key findings were as follows:
There was a track record and a culture of promptly responding to incidents, near misses and complaints and using these events to learn and change systems so that patient care could be improved. However, some policies and procedures were not being followed or monitored effectively. For example, infection control procedures did not identify the risks associated with the spread of infection and medicine processes had not being monitored to ensure checks were being carried out.
Staff were aware of their responsibilities in regard to consent, safeguarding and the Mental Capacity Act 2005 (MCA).
The practice was clean and tidy.
Medicines were managed well at the practice but temperature checks on refrigerated medicines were not always carried out and some documents required for the administration of vaccines had not been completed.
The GPs and other clinical staff were knowledgeable about how the decisions they made improved clinical outcomes for patients.
Data outcomes for patients were equal to the average locally. Where data had been identified as being lower than expected, plans were in place to improve the outcomes for patients.
Patients were complimentary about how their medical conditions were managed.
The practice was pro-active in obtaining as much information as possible about their patients which does or could affect their health and wellbeing. Staff knew the practice patients well, were able to identify people in crisis and were professional and respectful when providing care and treatment.
The practice planned its services to meet the diversity of its patients. There were good facilities available, adjustments were made to meet the needs of the patients and there was an effective appointment system in place which enabled a good access to the service.
The practice had a vision and informal set of values which were understood by staff. There was a leadership structure in place and staff felt supported.
We found areas where the provider MUST make improvements.
- The provider must protect patients and others against the risks associated with the unsafe use and management of medicines, by means of making of appropriate arrangements for the safe keeping, administration and disposal of medicines.
- The provider must ensure that patients and others are protected against identifiable risks of acquiring infection by an effective operation of systems to assess, prevent, detect and control the spread of infection.
We also found areas where the provider SHOULD make improvements. The provider should:
- Ensure systems are in place to ensure staff are aware of, follow and monitor the policies and procedures which govern activity. For example, infection control audits and procedures and medicines management. Fridge temperature management
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice