Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Riverside Kelsey Surgery on 6 June 2017. The overall rating for the practice was good; the practice was rated as good for providing services that were effective, caring, responsive and well-led. The safe domain was rated as requires improvement. The full comprehensive report on the June 2017 inspection can be found by selecting the ‘all reports’ link for Riverside Kelsey Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 22 February 2018 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 6 June 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as good.

Our key findings were as follows:

• The practice had undertaken a review of policies and procedures. And were in the process of having version control measures added to them.

• The practice had ensured that there was documentation to evidence all staff had received required training for their roles. The practice had updated their training matrix to identify when refresher training was required for each staff and booked these into the diary.

• All new employees had a completed health declaration questionnaire in their staff personnel files, completed as part of the recruitment checks.

• The practice had added a numerical coding system for significant events and complaints reporting. Each incident or complaint was given a code and all subsequent documents relating to that event were tagged to that code.

• The practice had increased their number of carers to just over 1% of the patient population.

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 Riverside Kelsey Surgery on 6 June 2017. Overall the practice is rated as good.

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. Reviews and investigations were completed but subsequent review documents were not always linked back to the original incident report.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care.
• There was evidence that audits were driving improvements to patient outcomes.
• Patients we spoke with 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 good facilities and was well equipped to treat patients and meet their needs.
• All of patients said they were treated with compassion, dignity and respect. All patients felt cared for, supported and listened to.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns. Patients were always responded to and where needed received an apology.
• The practice had a number of policies and procedures to govern activity. All policies had been reviewed but some policies lacked practice specific information.

The areas where the provider must make improvements are:

• Ensure recruitment arrangements include all necessary employment checks for all staff.

In addition the provider should:

• Review current process for recording discussions and actions following complaints and significant events to allow for easier monitoring of themes and trends.

• Ensure all staff have a record of completing training appropriate for their role and receive update training within expected timeframes.

• Review and update procedures and guidance to ensure they contain practice specific information.

• Review arrangements for identifying carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice