Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cumberland House Surgery on 21 July 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, well-led, effective, caring and responsive services. It was also good for providing services for all the population groups it serves.

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

• Systems were in place to ensure incidents and significant events were identified, investigated and reported. Staff understood and fulfilled their responsibilities to raise concerns and to report incidents. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Patients’ needs were assessed and care was planned and delivered in line with best practice guidance. Staff had received training appropriate for their roles and any further training needs had been identified and planned.
• Patients spoke highly about the practice and its staff. They 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.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care. Urgent appointments were available on the same day.
• 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.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should;

• Review the current arrangements for staff meetings to ensure all practice staff are included and given the opportunity to attend

• Strengthen the complaints and incident reporting systems in place by agreeing an action plan for improvements after such events. Also the practice should improve the system for staff to be able to report events when the management team are not available. This will enable closer monitoring and management of patient safety risks.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection July 2015 – Good)

The key questions 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 Cumberland House Surgery on 11 April 2018 this inspection was carried out 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.
• 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.
• Patients commented positively on the care received by the practice.
• The practice responded to complaints in a timely and open manner.
• Staff reported there was high staff morale and low turnover of staff.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw areas of outstanding practice:

• The practice had information about an interpreter service available in clinical rooms and waiting areas. The poster explained the service in four different languages and the practice explained the languages chosen represented the majority of the languages spoken by patients registered at the practice.
• The practice had commenced group consultations for patients with diabetes to use clinical time more effectively and to offer this group of patients peer support.

The areas where the provider should make improvements are:

• Carry out more detailed risk assessments with regard to the decision by the practice not to carry out Disclosure and Barring Service (DBS) checks on non-clinical staff to ensure the reason for the decision is clearly documented.
• The extended role of the health care assistant to support GPs with the triage system should be supported by a detailed protocol.
• Carry out a review of children on the child protection register to confirm the reason for inclusion on the register.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice