Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kings Lane Medical Practice - Dr D Kershaw on 5 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. Systems were in place for reporting, recording and learning from accidents, significant events and untoward incidents. Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses.
• Staff were trained in safeguarding and protection of children and vulnerable adults and understood their roles and responsibilities. Local authority guidance and protocols were accessible and staff were aware of how to raise concerns.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

• Patients were treated with care, compassion, dignity and respect and they were involved in their care and decisions about their treatment. They were given time at appointments and full explanations of their treatment were given. They valued their practice and felt confident with the skills and abilities of staff.

• We observed a strong patient-centred culture from dedicated staff.

• The practice proactively sought feedback from staff and patients, which it acted on. For example, amending the appointment system following surveys and patient participation group (PPG) feedback.
• Information about services and how to complain was available and easy to understand.
• Patients were able to access convenient appointments; however comments indicated there was a lack of continuity of care with GPs.
• The practice had good, modern 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 provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider should make improvement are:

• Review the audit program to include infection control audits being undertaken regularly and where local prescribing issues are identified, that these are audited to establish adherence to the local prescribing guidance.

• Review the practice’s policies and procedures including infection control policies and procedures to make them accessible to staff and up to date with current guidance and legislation.

• Review the process for learning from significant events and complaints to include regular reviews to learn from themes and trends and to monitor completion of action plans.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We found that suitable systems were in place and requirements relating to staff were obtained and held on file. This meant that people were cared for by staff who were appropriately recruited, qualified and able to carry out their role.

We looked at the systems in place and records held on file that demonstrated there were effective recruitment and selection procedures in place. Relevant checks were undertaken when staff were employed and to show that staff were registered with the relevant professional regulatory bodies

We found that patients were generally satisfied with the service provided at the practice. Comments made included:

“The service is wonderful, particularly the receptionists. They are always very pleasant, helpful and friendly”,

“I can’t speak too highly of the service. It’s marvellous”.

We found that there were suitable systems in place to gain consent from the patients. Staff who obtained consent were able to describe the consent process for both formal and informal consent. Staff demonstrated knowledge and understanding in the safeguarding of vulnerable adults and children.

We found that patients care and treatment was assessed, planned and delivered in order to meet their needs. Care and treatment plans were documented and reviewed and patients were fully informed and involved in their care or treatment.

We found that improvements were needed to the systems in place to assess the suitability of staff for their role and to ensure specified required information was available in respect of people employed.

We found the provider had effective systems in place for monitoring the quality of services. There was an active Patient Participation Group (PPG), complaints, incidents and significant events were reviewed and they participated in the QOF programme. QOF is a system for the performance management of GPs intended to improve the quality of general practice and reward good practice in surgeries.