Letter from the Chief Inspector of General Practice

This inspection was an announced comprehensive inspection that took place on 26 April 2017 and reviewed the provision of safe, effective, caring, responsive and well led services. We also reviewed evidence to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach of regulation that we identified in our previous inspection on 29 June 2016. On that occasion, we rated the practice as good for providing effective, caring and responsive services. However, a breach of the legal requirements was found which resulted in the practice being rated as requires improvement for providing safe and well led services. The full comprehensive report on the June 2016 inspection can be found by selecting the ‘all reports’ link for Crosland Moor Surgery on our website at www.cqc.org.uk.

The practice had made the required improvements to meet the legal requirements in the key question of safe and well led and is rated as good in all of the service areas we inspected.

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.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• 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 services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. However, some patients told us that it was sometimes more difficult to book a routine appointment in advance.
• The practice had good facilities and was well equipped, to treat patients and meet their needs. The building was accessible and a hearing loop was available for patients that would benefit from this.
• There was a clear and visible 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 area where the provider should make improvement is:

• Review the level of exception reporting in the area of cervical screening to be assured that eligible women are being encouraged to attend for screening.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice