Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection 15 October 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

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Gordon House surgery on 15 October 2015. The overall rating for the practice good. However we rated the key question as requires improvement and served the practice with a requirement notice for Regulation 17 in relation to improvements required in the safe and secure storage of patients paper records. The full comprehensive report can be found by selecting the Gordon House Surgery ‘all reports’ link for on our website at www.cqc.org.uk.

• This inspection was an announced comprehensive inspection carried out on 28 November 2017 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 on 15 October 2015. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

• 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.

The areas where the provider should make improvements are:

• Ensure they keep a log of all prescriptions.

• Maintain arrangements to safely store emergency equipment.

• Maintain arrangements of keeping a full supply of emergency medicines.

• Maintain mechanisms for managing a failsafe system for patients being referred under the cancer two week referral systems.

• Strengthen the system for following up and recording cervical smears.

• Ensure internal fridge temperatures are checked frequently

• Should continue their efforts to identify carers

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Gordon House Surgery on 19 October 2015. Overall the practice is rated as good.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Significant events were discussed regularly at practice meetings to share learning, although a complete audit trail was lacking in some documentation.
• Risks to patients were assessed and well-managed, with the exception of those relating to medicines storage and storage of patient paper records.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

• Patients said they felt the practice offered an excellent service and staff were kind, caring, supportive, and considerate and treated them with dignity and respect.
• Information about services and how to complain was available although some contact details were incorrect.
• Patients said they found it easy to make an appointment and 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 the management team. The practice proactively sought feedback from staff and patients, which it acted on.

• The practice engaged in local pilot schemes aimed at improving services and patient care.

We saw areas of outstanding practice:

• Practises put in place to raise awareness of Female Genital Mutilation (FGM).

• In-house educational meetings for patients to raise awareness of diagnosis and management of long-term conditions.

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

Importantly the provider must:

• Ensure confidential patient records are stored securely.

In addition the provider should:

• Review the processes in place for the recording of significant events to ensure that a clear audit trail is in place.

• Review the processes for recording actions taken in response to safety alerts.

• Review the fire safety arrangements in place to ensure that any responsibilities required of the practice are carried out.

  Review the process followed for monitoring fridge temperatures used to store medicines and vaccines to ensure a consistent approach.

• Review the arrangements in place for responding to medical emergencies to ensure that emergency equipment and medicines can be easily accessed.

• Ensure that information about making a complaint is up to date and made readily available to all patients.

• Review governance policies to ensure they reflect the correct external organisations.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice