15/06/2018
During a routine inspection
This practice is rated as Good overall. (Previous rating April 2015 – Good)
The key questions at this inspection are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We carried out an announced comprehensive inspection at South Hylton Surgery on 15 June 2018 as part of our inspection programme.
At this inspection we found:
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patient feedback was consistently positive. All 30 CQC comments cards we received were positive about the practice, this was in line with the results of the National GP Patient Survey. Patients we spoke with were positive about the practice.
- Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
- At our previous inspection in April 2015, we told the provider that they should make improvements in some areas. We saw at this inspection improvements had been made. The practice had completed a legionella risk assessment, ensured the security of prescription forms and had improved the systems in place for recalling patients experiencing mental health problems for review.
We saw one area of outstanding practice:
- The service understood the needs of different people and groups of people, and delivered care and support in a way that meets these needs and promoted equality. They encouraged patients with learning disabilities and dementia to have care reviews completed in their home environment. This was to reduce stress and anxiety for patients. For 2017/2018, 52% of patients with a learning disability and 59% of patients with dementia had their review completed at home. For the remaining patient’s, reviews had been completed at the practice. This was due to patient choice or because the patient attended the practice for another reason and the review appointment had been booked to coincide with this. This reduced the number of times the patient needed to attend the practice.
The areas where the provider should make improvements are:
- Review their process when managing significant events so that they always act in accordance with the Duty of Candour.
- Evaluate and improve the systems in place for exception reporting patients at the practice.
- Act so that all persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties. Specifically, complete staff appraisals for those staff who had not been appraised in the last 12 months.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.