Kennedy Way Surgery in Yate, Bristol is a Doctors/GP specialising in the provision of services relating to diagnostic and screening procedures, family planning services, maternity and midwifery services, services for everyone, surgical procedures and treatment of disease, disorder or injury. The last inspection date here was 12th October 2018
Kennedy Way Surgery is managed by Kennedy Way Surgery.
Contact Details:
Address:
Kennedy Way Surgery Kennedy Way Yate Bristol BS37 4AA United Kingdom
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Kennedy Way Surgery
on 19 April 2016. Following our comprehensive inspection overall the practice was rated as good with requires improvement for the safe domain. Following the inspection we issued three requirement notices:
One notice was issued due to a breach of Regulation 12 of The Health and Social Care Act (Regulated Activity) Regulations 2014, Safe care and treatment. The requirement notice was for the practice to implement the necessary changes to ensure patients who used the service were protected against any risks associated with the safe management of the medicines, the safety of emergency equipment and the safe management of blank prescriptions.
The second notice was issued due to a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Premises and Equipment. The requirement notice was for the practice to implement the necessary changes to ensure patients who used the service were protected against any risks associated with the health and safety of service users. Specifically the risks associated with infection control and legionella assessment.
The third notice was issued due to a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staffing. The requirement notice was for the practice to implement the necessary changes to ensure patients who used the service were protected against any risks associated with the employment of locum staff by ensuring there was evidence on site which provided assurance of their professional qualifications and training.
A copy of the report detailing our findings can be found at www.cqc.org.uk.
Our key findings across all the areas we inspected were as follows:
The areas where the provider must make improvement were:
The practice must ensure that the policies for medicines management including prescription security were fully implemented and monitored.
The practice must ensure there was evidence on site which provided assurance of the professional qualifications, Disclosure and Barring Service (DBS) checks and training for all the of the staff who worked at the practice.
The practice must undertake an infection control audit and include a legionella assessment.
The areas where the provider should make improvement are:
The practice should record emergency equipment checks for all the equipment designated for this purpose to ensure it is still within its ‘use by’ date.
The practice should review waste management storage to ensure it is not accessible by the public.
The practice should have an electrical safety check against the UK standard for the safety of electrical installations, BS 7671 – Requirements for Electrical Installations (IEE Wiring Regulations).
We undertook this focused inspection on 19 October 2016 to follow up the requirement to assess if the practice had implemented the changes needed to ensure patients who used the service were safe.
Our key findings across all the areas we inspected during this inspection were as follows:
The practice had reviewed and rewritten their medicine management protocols, processes for prescription security and checking emergency equipment; these had been fully implemented by the practice.
The practice had ensured all employees had a DBS check; we noted that for locum and agency staff the required checks had been completed and were held on their personnel file.
The practice had completed an infection control audit and provided evidence ofa legionella assessment. We found waste management storage had been reviewed and made inaccessible to the public.
The practice had evidence of an electrical safety check against the UK standard for the safety of electrical installations, BS 7671 – Requirements for Electrical Installations (IEE Wiring Regulations).
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Kennedy Way Surgery on 19 April 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 an effective system in place for reporting and recording significant events.
Risks to patients were assessed and well managed.
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.
The practice had good appointment access as patients who call any time between 8am and 4pm could speak to a GP and can be seen that day by the GP of their choice. Patients confirmed they found it easy to make an appointment with a GP and there was continuity of care.
The practice had identified vulnerable groups of patients and provided opportunities for group such as ex-military patients with access to a GP who had military experience.
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.
Patients had nominated the practice for a GP of the Year at the Bristol Health and Care Awards 2016 at which they were runners up.
The provider was aware of and complied with the requirements of the duty of candour.
The areas where the provider must make improvement are:
The practice must ensure that the policies for medicines management including prescription security are fully implemented and monitored.
The practice must ensure there was evidence on site which provided assurance of the professional qualifications, Disclosure and Barring Service (DBS) checks and training for all the of the staff who worked at the practice.
The practice must undertake an infection control audit and include a legionella assessment.
The areas where the provider should make improvement are:
The practice should record emergency equipment checks for all the equipment designated for this purpose to ensure it is still within its ‘use by’ date.
The practice should review waste management storage to ensure it is not accessible by the public.
The practice should have an electrical safety check against the UK standard for the safety of electrical installations, BS 7671 – Requirements for Electrical Installations (IEE Wiring Regulations).
During our visit to the surgery we spoke with three patients, one GP, the practice manager, the deputy manager, the practice nurse, a receptionist and a health care assistant. After our visit we spoke with a further eight patients over the phone in order to gather their views about the service. People expressed satisfaction with the service they had received. One patient said "the GP takes time to explain so it is simple and understandable." Another patient said “it is an excellent surgery, I cannot fault it in anyway at all”.
People’s privacy, dignity and independence were respected. People’s views and experiences were taken into account in the way the service was provided and delivered in relation to their care. People who used the service told us that the GP explained treatment options.One patient said "I explained the problems I had been experiencing.We discussed them and I got a choice of treatment options with the risks and benefits explained to me".
Staff were clear about what action they would take if they saw or suspected any bad practice or abuse.Staff had been given information about safeguarding adults but had not yet received formal training in this area.
There were effective systems in place to monitor the quality of the service provided and patients felt able to give feedback about the service they received.
This practice is rated as Good overall. (Previous rating April 2016 – Good)
The key questions at this inspection 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 Kennedy Way Surgery on 4 September 2018 as part of our risk based inspection programme.
At this inspection we found:
There had been a significant change in the leadership at the practice over the past 12 months with the retirement of the senior partner who was also the registered manager. This had been impacted further by unforeseen circumstances in the management team. We found the practice had adapted well to accommodate the situation. This was reinforced from the feedback from patients we spoke with during the 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 focus on continuous learning and improvement at all levels of the organisation.
The areas where the provider should make improvements are:
Develop a written protocol for verifying and recording the identity of patients during remote or online consultations.
Review the system for recording and taking action for when the medicines refrigerator indicated a temperature reading outside of the expected range.
The practice should review the process for patient group directives (written instructions to administer medicines to a group of patients) to ensure they are always signed appropriately and are in date.
The practice should risk assess the emergency medicines not kept as recommended by the UK Resuscitation Council.
Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.
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