Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Elizabeth Densham on 22 March 2016. The overall rating for the practice was good. However they were rated as requires improvement in safe. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Dr Elizabeth Densham on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 16 January 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in March 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

• The practice had some 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.

The areas where the provider should make improvements are:

• Continue to identify carers in order for them to receive appropriate care and support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We spoke with six people who used the service and looked at comments from people on the NHS Choices website. Most people were satisfied with the care they had received. People told us that they could usually get an appointment when they wanted and most were able to be seen in an emergency. Comments included "excellent," "no problems at all" and "Dr Densham has been there for me". People felt that they were involved in making decisions about their care and felt that their GP explained everything to them. Most people told us they got enough time with their GP.

People received care that ensured their safety and welfare and protected them from the risk of abuse. They were assessed and treated by a qualified clinician who arranged for diagnostic tests or a referral to another service, if appropriate. There were systems in place to deal with emergencies. Staff had received basic life support training and there was emergency equipment available.

There were systems in place to monitor the quality of service provided and to ensure that people's records were accurate and secure. People were encouraged to make comments and complaints and we saw evidence that incidents were investigated appropriately. The provider had carried out a variety of audits in order to meet the Quality and Outcomes Framework (QOF) targets. Meetings with other health professionals took place on a regular basis to discuss individual cases and audit topics.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Elizabeth Densham 11 February and 22 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.
• 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.
• Patients said 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

• Ensure staff receive appropriate training to enable them to carry out their duties, such as infection control, adult safeguarding, Health and Safety, Fire safety and Information governance.

• Implement formal clinical supervision arrangements for the nurse practitioner.
• Implement processes to monitor that NICE clinical guideline are followed by all clinical staff.

The areas where the provider should make improvement are:

• Ensure regular analysis of the significant events and complaints are carried out in order for the practice to identify any themes emerging and put systems in place to prevent them re-occurring.
• Replace the carpets in the treatment room with washable flooring as identified in the audit undertaken in 2013.

• Document in patients notes if they had refused a chaperone when offered

• Develop a register of carers in order to provide appropriate information for them.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice