Letter from the Chief Inspector of General Practice

This was a focused desk top review of evidence supplied by Block Lane Surgery for areas within the key question effective that required improvement following our full comprehensive inspection under the Health and Social Care Act 2008. At that inspection on 3 March 2016, the practice was rated good overall. However, within the key question effective there was an area identified as requiring improvement where the practice was not meeting the legislation at that time. The area where the provider was told they must make improvement was as follows:

• Regulation 17 HSCA (RA) Regulations 2014 Good governance. The provider did not complete clinical audit cycles as a way to improve patient care and implement change. This was in breach of regulation 17 (1) (2) (a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

In addition there were a number of areas areas where the provider was told they should make improvement. These were as follows :

• The provider should put a system in place to check the professional registration status of all clinicians.
• The recruitment policy should be updated to include all aspects of pre-employment checking.
• The provider should improve their system of analysing significant events to ensure the events are not repeated and learning actions have completed.
• The provider should update their business continuity plan so that all information is current and all sections of the plan complete.
• The provider should ensure all the information about complaints in their policies and on the website is up to date.

We received and assessed documentation to evidence that the practice had carried out their action plan to make improvements. They now meet the required level in relation to breaches in Regulation 17. They also provided evidence to show that other improvements had been made.

The overall rating for the practice remains as good. Our key findings were as follows:

• Clinical audits were logged and managed by the practice manager. A spreadsheet with check points ensured that two-cycle audits were completed. Clinical audits were presented to clinicians at the practice meeting.
• The business continuity plan had been reviewed and updated.
• Professional registration was reviewed on a quarterly basis and entries were checked and recorded in a spreadsheet.
• The recruitment policy had been updated to reflect all aspects of pre-employment checks.
• There was a system in place to ensure that significant events were reviewed on a regular basis.
• The complaints procedure, patient leaflet and practice website had been updated and aligned.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Block Lane Surgery on 3 March 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• 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.
• Patients said they could make an appointment with a GP and that there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvement are:

• The provider must ensure clinical audits cycles take place as a way of making improvements to the service provided.

The areas where the provider should make improvements:

• The provider should put a system in place to check the professional registration status of all clinicians.

• The recruitment policy should be updated to include all aspects of pre-employment checking.

• The provider should improve their system of analysing significant events to ensure the events are not repeated and learning actions have completed.

• The provider should update their business continuity plan so that all information is current and all sections of the plan complete.

• The provider should ensure all the information about complaints in their policies and on the website is up to date.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice