Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Yuen Fong Soloman Wong (known as Ashton View Medical Centre) on 18 May 2016. Overall, the practice is rated as good for providing safe, effective, caring, responsive and well-led care for all of the population groups it serves.

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

• The practice complied with the requirements of the duty of candour. (The duty of candour is a set of specific legal requirements that providers of services must follow when things go wrong with care and treatment.)
• The practice promoted a culture of openness and honesty. All staff were encouraged and supported to record any incidents using the electronic reporting system. There was evidence of good investigation, learning and sharing mechanisms in place.
• Risks to patients were assessed and well managed.
• There were safeguarding systems in place to protect patients and staff from abuse.
• The practice sought patient views how improvements could be made to the service, through the use of patient surveys, the NHS Friends and Family Test and engagement with patients.
• There was a clear leadership structure, staff were aware of their roles and responsibilities and told us the GP and manager were accessible and supportive.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance.
• Staff had the skills, knowledge and experience to deliver effective care and treatment.
• The practice had good facilities and was equipped to treat and meet the needs of patients.
• Information regarding the services provided by the practice and how to make a complaint was readily available for patients.
• Patients said they found it generally easy to make an appointment, there was continuity of care and urgent appointments were available on the same day as requested. The practice provided a combination of booked appointments and a daily walk-in clinic for patients.
• The practice provided a NHS non-therapeutic (for religious or cultural reasons) circumcision service, for male babies up to the age of 12 weeks. Registered patients with all GP practices across the three Leeds Clinical Commissioning Groups had access to the service.
• Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were either comparable or below the national average. This was discussed with the practice and data they had collated for 2015/16 showed improvements.

There was one area where the provider should make improvements:

• Continue to monitor Quality and Outcomes Framework results to improve outcomes for patients.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

At the last inspection in January 2014 we found the registered person had not ensured that patients, staff and others were protected against identifiable risks of infection Regulation 12 (1) (2).

At this inspection we found people were cared for in a clean, hygienic environment.

We spoke with four patients at the practice, four members of staff, the practice manager and the full-time doctor. Patients told us they were satisfied with the practice and did not have difficulty obtaining an appointment.

The practice information leaflet included details of the staff at the practice, the services available, the surgery times, how to make an appointment and an emergency contact number.

The waiting room included a good range of neatly organised health promotion and advice leaflets. Information about the practice Patient Participation Group (PPG) was clearly displayed on a separate notice board.

Staff were courteous and respectful to patients and visitors to the practice. They dealt efficiently with enquiries and there appeared to be a good rapport among the staff.

New patients were asked to provide details of their medical history, tobacco and alcohol consumption and where appropriate details of their carer or anyone they cared for. Patients were offered an appointment with the practice nurse for an initial health screen. Patients with on-going medical needs were prioritised for an appointment with one of the doctors.

Arrangements to reduce the risk and spread of infection were inadequate. The practice did not have a policy describing procedures for the identification and control of risks of infection. Some staff had not had training in infection control procedures.

Staff said they enjoyed working at the practice. They said the practice manager was very good and they felt well supported. One member of staff said they were, “Treated with respect as a member of staff and colleague.”

The practice participated in local clinical audit programmes and also carried out its own health and safety checks. The practice had made a suggestion/comments box available for patients. Efforts had also been made to encourage patients to join a Patient Participation Group (PPG) to advise the practice on improvements to the service.