Letter from the Chief Inspector of General Practice

This is a focused desk top review of evidence supplied by Meadow View Surgery, for areas within the key question well-led. This review was completed on 13 July 2017.

Upon review of the documentation provided by the practice, we found the practice to be good in providing well-led services. Overall, the practice is rated as good.

The practice was previously inspected on 15 November 2016. The inspection was a comprehensive inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (HSCA). At the inspection, the practice was rated overall as ‘good’. However, within the key question well-led an area was identified as ‘requires improvement’, as the practice was not meeting the legislation in respect of good governance. The practice was issued a requirement notice under Regulation 17, good governance.

At the inspection in November 2016 we found the provider did not have a strategy to deliver the practice vision, policies & procedures were not in all cases up to date and there was no program of quality improvement including clinical audit to drive improvement in patient outcomes.

The practice supplied an action plan and a range of documents which demonstrated they are now meeting the requirements of Regulation 17 good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These improvements have been documented in the well-led section, showing how the registered person has demonstrated continuous improvement since the full inspection.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Following a comprehensive inspection of Meadow View Surgery in January 2015 the practice was rated as requires improvement for providing safe and well-led services and good for providing effective, caring and responsive services. The practice was given an overall rating of requires improvement. At the inspection shortfalls were identified in relation to patient confidentiality, infection control, general health and safety and the management of medicines.The practice was found to be in breach of two regulations and requirement notices were set for regulations 12 and 17 of the Health and Social Care Act 2008.

We then carried out an announced comprehensive inspection at Meadow View Surgery on 15 November 2016 to check that improvements had been made Overall the practice is rated as good.

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

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• 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.
• 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 with the exception of those relating to the control of substances hazardous to health.
• 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.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had adequate facilities and was 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:

• Develop a clear strategy to deliver the practice vision.

• Develop a programme of quality improvement including clinical audit to drive improvement in clinical outcomes.

• Review and update all practice policies and procedures.

​In addition the provider should:

• Complete a risk assessment for the control of substances hazardous to health.

• Identify and support more patients who are carers.

• Consider ways to support patients who are hard of hearing.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This is a focused desk top review of evidence supplied by Meadow View Surgery, for areas within the key question well-led. This review was completed on 13 July 2017.

Upon review of the documentation provided by the practice, we found the practice to be good in providing well-led services. Overall, the practice is rated as good.

The practice was previously inspected on 15 November 2016. The inspection was a comprehensive inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (HSCA). At the inspection, the practice was rated overall as ‘good’. However, within the key question well-led an area was identified as ‘requires improvement’, as the practice was not meeting the legislation in respect of good governance. The practice was issued a requirement notice under Regulation 17, good governance.

At the inspection in November 2016 we found the provider did not have a strategy to deliver the practice vision, policies & procedures were not in all cases up to date and there was no program of quality improvement including clinical audit to drive improvement in patient outcomes.

The practice supplied an action plan and a range of documents which demonstrated they are now meeting the requirements of Regulation 17 good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These improvements have been documented in the well-led section, showing how the registered person has demonstrated continuous improvement since the full inspection.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice