Letter from the Chief Inspector of General Practice

We carried out a desk-based review of evidence requested from The Hawthorns Surgery on 23 August 2016. Overall the practice is rated as good.

During our previous inspection of the practice on 26 November 2015 the practice was rated requires improvement for the safe domain. The practice was issued with one requirement notice for breaches in regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The issues related to legionella risk assessments not being in place and ensuring systems were in place to monitor the use of prescription stationery.

This desk-based review was to assess the action that had been taken by the provider since the last inspection through a review of evidence relating to the issues identified previously. For this reason we have only rated the location for the safe domain. The report should therefore be read in conjunction with the full inspection report published in February 2016.

Through a review of the information sent to us by the provider we found the practice had made changes since their previous inspection in November 2015. We found that robust action had been taken regarding the issues identified at the previous inspection and that the practice was now meeting the requirements of the standards. This meant that the practice was now rated as good in safe domain. All other domains were already previously rated as good.

Specifically we found that since the last inspection:

• The practice had developed and implemented a robust new policy to monitor the use of prescription stationery.

Risks to patients were assessed and well managed. A legionella risk assessment had been completed and the practice had implemented the recommendations to minimise risk.

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 The Hawthorns Surgery on 26 November 2015. Overall the practice is rated as good.

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

• Staff we spoke with understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We saw evidence to demonstrate that learning was shared amongst staff.
• Risks to patients were assessed and well managed, with the exception of those relating to legionella risk.
• 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.
• Patients we spoke with told us 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 with a complaints poster displayed in the waiting area and complaints information also found in the practice leaflet.
• The practice had good facilities and was well equipped to treat patients and meet their needs. There were disabled facilities, hearing loop and translation services available as well as ramped access and automatic entrance doors leading onto the car park with marked disabled parking bays.
• The practice had a clear vision to deliver high quality care and promote good outcomes for patients. It had a mission statement underpinned by practice principles and staff we spoke with knew and understood these.
• Patients said they did not find it easy to make a routine appointment with a named GP although urgent appointments available the same day.
• The practice had carried out clinical audits and re-audits to improve patient outcomes.
• There was a clear leadership structure and staff we spoke with felt supported by both management and the GP partners although proactive engagement with the patient participation group had not been prioritised.

The areas where the provider must make improvements are:

• Ensure risk assessments and arrangements are in place to minimise the risk of legionella.

• Ensure there are systems in place to monitor the use of prescriptions.

In addition the provider should:

• Improve engagement with the patient participation group

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We reviewed the information available to us about The Hawthorns Surgery on 7 June 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.