Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 17 November 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 an effective 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 been trained to provide them with 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 how to complain was available and easy to understand. Comments and complaints were analysed and improvements were made to the quality of care as a result of complaints and concerns.
• 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 provider was aware of and complied with the requirements of the duty of candour.

Professor Steve Field

CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

This report is a follow up to our report published in August 2013. We had inspected this provider on the 18 and 20 June 2013.

We noted some issues which had minor or moderate impacts on people using the service. These related to the safety and suitability of the premises, cleanliness and infection control, requirements relating to workers and record keeping. We set various compliance actions requiring the provider to take steps to comply with Regulations 12, 15, 20 and 21 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Following our inspection in June, we had asked the provider to send us an action plan setting out what would be done to meet the requirements of the regulations. The action plan was received in August. We carried out this inspection to check on the action the provider had taken to meet the requirements of the regulations.

We found that improvements had been made and that the provider had taken appropriate and sufficient action to comply with the Regulations.

We inspected the practice on the 18th and 20th June 2013. We spoke with the provider, practice manager, the practice’s two nurses and staff members. We also spoke with a number of people attending appointments and with the chair of the newly established patients’ participation group. We looked at a number of treatment records and other records relating to the service. We also looked at comments about the service which people had added to the NHS Choices website and saw the results of the practice's own 2012 / 13 patient survey.

People who use the service were very complimentary about the practice. One person said, “They are marvellous to me.” Another said, “The treatment is good and the staff here are excellent. They often go that extra mile.”

The practice regularly sought the views of people using the service to monitor performance. The patients’ participation group had been set up to improve service user involvement.

We had some concerns regarding the cleaning procedures at the premises and noted that the practice had failed to carry out necessary fire safety checks. People’s healthcare records were well-maintained, but the standard of record keeping relating to policies and procedures and staff members' personnel records was not sufficient. We have set compliance actions accordingly.

The staff team worked well together and were appropriately supported to undertake training and gain experience.