Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Poplars Medical Practice on 18 November 2015. A total of one breach of legal requirement was found. After the focussed inspection, although the practice was rated good overall, it was rated as requires improvement for providing safe services. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Poplars Medical Practice on our website at www.cqc.org.uk.

Following the inspection in November 2015 we issued requirement notices in relation to:

• Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Safe care and treatment.

This inspection was a desktop focused inspection carried out on 20 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified at our previous inspection on 18 November 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection

Our key findings 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 and staff were assessed and health and safety risk audit records improved to ensure sufficient information was recorded to demonstrate the level of risk, action to be taken and by whom.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. The female locum GP who was working at the practice at the time of the  inspection in November 2015 had left. To address this the advanced nurse practitioner had the skills to meet some of the clinical needs of female patients registered at the practice. Female patients were made aware of this and potential female patients were made aware that the practice did not have a female GP. This ensured that they could make an informed decision as to whether they wanted to register as a patient at the practice.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The appointment system had been reviewed and changes made to improve patients experiences. Changes were monitored to ensure the length of time patients had to wait to be seen at their appointment showed ongoing improvement.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Clinical audits had been carried out to monitor the quality of service provided to patients.

• There was a clear leadership structure and staff felt supported by the management.
• The practice proactively sought feedback from patients. The practice worked effectively with the patient participation group to encourage active involvement in the improvement of the practice. The group was discussing the possibility of a virtual group.
• The provider was aware of and complied with the requirements of the Duty of Candour.

At this inspection we found that the practice had acted on the concerns identified at the inspection November 2015 and as a consequence ratings for the practice has been updated to reflect our most recent findings. The practice is now rated as good for providing safe services.

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 Poplars Medical Practice on Wednesday 18 November 2015.

This inspection was in follow up to our previous comprehensive inspection at the practice on 8 December 2014 where breaches of legal requirements were found. The overall rating of the practice following the 2014 inspection was inadequate and the practice was placed into special measures for a period of six months. After the inspection in December 2014 the practice wrote to us to say what they would do to meet legal requirements in relation to providing safe, effective, responsive and well-led services.

At our inspection on 18 November 2015 we found that the practice had improved. The five requirement notices we issued following our previous inspection related to the delivery of safe, effective and well-led care and all had been met. The ratings for the practice have been updated to reflect our most recent findings. 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 and staff were assessed; however completed health and safety risk audit records did not contain sufficient information to demonstrate the level of risk, action to be taken and by whom.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Disclosure and barring checks (DBS) had been completed for all staff.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients were concerned about the length of time they had to wait to be seen at their appointment.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Clinical audits had been carried out to monitor the quality of service provided to patients.
• There was a clear leadership structure and staff felt supported by management. Although further improvement was still needed the practice had sought feedback from patients and had a patient participation group.

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

Importantly, the provider must:

• Provide a suitable means to provide high-flow oxygen therapy to patients in an emergency situation.

The areas where the provider should:

• Improve record keeping of significant events to evidence investigation, discussion and learning from the events.
• Complete the action points contained in the practice Legionella risk assessment.
• Review the method of handling blank prescriptions within the practice to reflect national recognised guidance as detailed in NHS Protect
• Consider carrying out a review of the appointments system.
• Consider how the patient participation group can be encouraged and supported to be more involved in the continuous improvement of the practice.

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 Poplars Medical Practice on 18 November 2015. A total of one breach of legal requirement was found. After the focussed inspection, although the practice was rated good overall, it was rated as requires improvement for providing safe services. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Poplars Medical Practice on our website at www.cqc.org.uk.

Following the inspection in November 2015 we issued requirement notices in relation to:

• Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Safe care and treatment.

This inspection was a desktop focused inspection carried out on 20 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified at our previous inspection on 18 November 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection

Our key findings 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 and staff were assessed and health and safety risk audit records improved to ensure sufficient information was recorded to demonstrate the level of risk, action to be taken and by whom.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. The female locum GP who was working at the practice at the time of the  inspection in November 2015 had left. To address this the advanced nurse practitioner had the skills to meet some of the clinical needs of female patients registered at the practice. Female patients were made aware of this and potential female patients were made aware that the practice did not have a female GP. This ensured that they could make an informed decision as to whether they wanted to register as a patient at the practice.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The appointment system had been reviewed and changes made to improve patients experiences. Changes were monitored to ensure the length of time patients had to wait to be seen at their appointment showed ongoing improvement.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Clinical audits had been carried out to monitor the quality of service provided to patients.

• There was a clear leadership structure and staff felt supported by the management.
• The practice proactively sought feedback from patients. The practice worked effectively with the patient participation group to encourage active involvement in the improvement of the practice. The group was discussing the possibility of a virtual group.
• The provider was aware of and complied with the requirements of the Duty of Candour.

At this inspection we found that the practice had acted on the concerns identified at the inspection November 2015 and as a consequence ratings for the practice has been updated to reflect our most recent findings. The practice is now rated as good for providing safe services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice