Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Roundhay Road Surgery on 29 June 2016. Overall the practice is rated as good for providing safe, effective, caring, responsive and well-led care for all of the population groups it serves.

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

• The practice staff had a very good understanding of the needs of their practice population and were flexible in their service delivery to meet patient demands; such as providing additional GP appointments when required.
• Many of the staff were multilingual which supported effective communication with their patients.
• There was a clear leadership structure, staff were aware of their roles and responsibilities and told us the GPs were accessible and supportive. There was evidence of an all inclusive team approach to providing services and care for patients.
• Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients’ needs were assessed and care was planned and delivered following local and national care pathways and National Institute for Health and Care Excellence (NICE) guidance.
• Patients said they found it generally easy to make an appointment. There was continuity of care and if urgent care was needed patients were seen on the same day as requested.
• Information regarding the services provided by the practice and how to make a complaint was readily available for patients.
• The practice complied with the requirements of the duty of candour. (The duty of candour is a set of specific legal requirements that providers of services must follow when things go wrong with care and treatment.)
• The practice promoted a culture of openness and honesty. There was a nominated lead who had a very organised approach for dealing with significant events. All staff were encouraged and supported to record any incidents using the electronic reporting system. There was evidence of good investigation, learning and sharing mechanisms in place.
• Risks to patients were assessed and well managed.
• There were safeguarding systems in place to protect patients and staff from abuse.
• The practice sought patient views how improvements could be made to the service, through the use of patient surveys, the NHS Friends and Family Test and engagement with patients and their local community.

We saw some areas of outstanding practice:

• The practice facilitated an annual ‘healthy eating’ open day to provide information for patients on how to grow, eat and cook food more healthily; particularly Asian cuisine in relation to diabetes. Anecdotal and photographic evidence showed these events were well attended.
• At the suggestion of the patient participation group, the practice had set up a weekly pilates class. This had been ongoing for the past two years and both patients and staff had access to the classes. As a result of positive feedback and attendance classes had increased to twice a week.
• There were dedicated staff ‘champions’ for cancer screening, immunisation programmes and long term condition (LTC) reviews. (Practices with disproportionately high ethnic minority populations are usually associated with low uptake rates.) They contacted patients and provided information. Often staff were able to speak to the patient in their own language to aid understanding. As a result, uptake for LTC reviews, screening and immunisations were higher than CCG and national averages. 

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Our inspection on the 28th January 2014 we found the provider did not have robust systems in place to reduce the risk and spread of health care associated infections. Following the inspection the provider wrote to us and told us they would take action to ensure they were compliant with these essential standards.

On this visit we found that improvements had been made. The provider had put in place appropriate measures to ensure that they were compliant with the essential standards and people's health was protected by robust systems being in place.

We spoke with four patients, four members of staff, the practice manager, a practice nurse and a doctor at the practice. Patients were very complimentary about the practice. They told us the staff were, “Always welcoming,” “Very friendly” and “Willing to help.” One said they felt they were well cared for and it was a, “Good family orientated practice.”

Patients told us they were usually able to obtain an appointment at the practice at times which were convenient for them. They said they felt involved in decisions about their care and treatment. The doctor or nurse took time to explain their treatment and the risks and benefits were explained to them.

The practice had put in place some measures to protect patients and staff from the risks of infection. However the measures were ineffective and recommended good practice guidance had not been followed.

The staff we spoke with told us they enjoyed their jobs. They said there was good teamwork and they were well supported.

The practice participated in local clinical audit programmes. Patients were invited to submit comments or suggestions for improvement of the service and were encouraged to contribute to the practice Patient Participation Group (PPG).