Letter from the Chief Inspector of General Practice

This was the second comprehensive inspection that we had carried out at Thistlemoor Medical Practice

On 3 September 2015, we carried out a focused inspection of Thistlemoor medical practice. The practice was rated as outstanding overall and rated as outstanding for providing effective, responsive, and well led services and good for providing safe and caring services.

Since our previous inspection the Care Quality Commission received reports from anonymous sources relating to the safe and effective care of patients at the practice.

We carried out a short notice announced comprehensive inspection at Thistlemoor Medical practice on 1 August 2016. Prior to the on-site inspection, all staff members were provided with the direct mobile telephone number of the lead inspector. The inspector was available from 8am to 9pm on Friday 29 July 2016 and from 10am to 6pm Sunday 31 July 2016. This gave all staff the opportunity to speak directly with the inspector at a time and a place that was convenient to them. We focused our inspection on the safe and effective domains.

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 were assessed and well managed.

• 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.

• 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.

• The practice had good facilities and was well 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 training and education systems in place were robust and competency assessment undertaken and evidenced appropriately.

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 Thistlemoor Surgery on 3 September 2015. Overall the practice is rated as outstanding.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.

• The practice was actively involved in local and national initiatives to enhance the care offered to patients. They were proactive in trialling new ways of working to ensure they continued to meet the needs of the patients.

• Patients said they were treated in a way that they liked and they were involved in their care and decisions about their treatment. Information was provided in a range of formats and languages to help patients understand the care available to them.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group (PPG). Information about how to complain was available and easy to understand.

• There was a structured system for providing staff in all roles with annual appraisals of their work and planning their training needs.

• The practice undertook a wide range of both clinical and non clinical audits to drive improvements in patient care.

• There was a clear leadership structure and staff felt supported by management.

• The practice had a clear vision that had quality and safety as its top priority. High standards were promoted and owned by all practice staff with evidence of team working across all roles.

We saw several areas of outstanding practice including:

• The practice offered a wide range of extended hour opening times, both early in the morning, the early evening and on Saturday mornings. The practice operated a walk in surgery each morning which meant that patients who attended between 8.30am and 10.30am were seen. Patients we spoke with particularly valued this walk-in service.

• Health care assistants were key members of the practice team and most spoke a range of languages, including those spoken by many of the practice’s population group. This supported good communication and patients’ involvement in understanding and managing their care.

• The practice offered health checks for 40-75 year olds. Despite already meeting its target to complete 300 of these for the year 2015-2016, it had decided to continue with these checks so that patients’ health and well-being could be monitored.

• The practice offered smoking cessation clinics in different languages to meet the needs of its patients, many of whom did not have English as their first language. These clinics had been successful in helping 70% of those who had attended to give up smoking (56 patients in total).

• The practice’s premises provided excellent facilities for patients. There was a resource room containing a range of health information for patients; a prayer room for use by both staff and patients; a room for mothers to breast feed their babies in private and two sound proof rooms where staff could telephone patients confidentially and without distraction.

• A local councillor told us that the practice was very engaged with local schools, inviting school parties to visit and talking to children about the work of doctors and nurses.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Thistlemoor Road Surgery provides a primary health care service for approximately 15,000 patients. At the time of our inspection, there were three partner GPs. They employed five salaried GPs. A trainee GP and a junior doctor undertaking foundation training were completing placements there. There were four nurses; 11 health care assistants (HCAs) and a team of administrators and receptionists. Health visitors and district nurses are located within the practice building and other healthcare staff hold clinics there.

We checked to see if services were safe, effective, caring, responsive and well-led. We found that Thistlemoor Road Surgery met all of these criteria. We looked at how the practice provided services for patients who were aged over 75; for patients with long-term conditions; for mothers, babies, children and young people; for patients of working age and those recently retired; for patients in vulnerable circumstances who may have poor access to primary care and for patients experiencing poor mental health. We found evidence of positive care for patients in each of these groups.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.