Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection of Three Villages Medical Practice on 18 January 2017. The overall rating for the practice was good with requires improvement for providing a safe service. The full comprehensive report on the 18 January 2017 inspection can be found by selecting the ‘all reports’ link for Three Villages Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 10 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations identified at our previous inspection on 18 January 2017. This report covers our findings in relation to those requirements.

Our key findings were as follows:

• An effective system had been implemented to ensure clinical alerts such as those from the Medicines and Healthcare products Regulatory Agency (MHRA) were communicated to appropriate staff and appropriate actions taken.
• The practice had effective systems to manager patients experiencing poor mental health (including people with dementia).  

Further improvements included:

• A strong relationship had been developed with the patient participation group and we saw that active engagement was supported and encouraged by the practice.
• In 2017, the practice had achieved an increase in 18 of the 22 indicators that make up the annual National GP Survey.
• Quality performance data for patient outcomes was consistently above average when compared to other local practices and overall performance positioned in the practice in the best quartile for Dudley Clinical Commissioning Group (CCG).

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 Three Villages Medical Practice on 18 January 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 report incidents and near misses. All opportunities for learning from incidents were maximised.

• Although the practice had implemented processes and practices to minimise risks to patient safety, we saw areas where alerts received

  from the Medicines and Healthcare products Regulatory Agency (MHRA)

  were not consistently actioned in line with practice processes.

• Although the practice used clinical audits to drive improvements to patient’s outcomes, quality performance data showed patient outcomes were low in some clinical areas compared to the local and national average. However, these results were based on partial data as the practice opted into a local framework from October 2015 and were actively monitoring the use of this framework.

• The practice worked closely with other organisations in planning how services were provided to ensure that they meet patients’ needs. For example, the practice was keen on being a part of the Multi-speciality Community Provider (MCP) to improve services internally and locally once the networks were up and running.

• Most of the results from the national GP patient survey showed patients rated the practice positively.
• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from national GP patient survey results. The practice carried out surveys in light of changes to monitor patient satisfaction.

• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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. However, results from the national GP patient survey showed that patient’s satisfaction with how they could access care and treatment was below local and national averages.
• The practice had a clear vision which had quality as its top priority. The strategy to deliver this vision was regularly reviewed and discussed with staff.
• Although the practice had strong and visible clinical and managerial leadership and governance arrangements; oversight of some governance arrangements were not being monitored effectively. As a result, this led to areas where systems were not being operated effectively and there were differences’ in the views of the practice and their patient participation group regarding the effectiveness of the communication pathways.  

There were areas of practice where the provider must make improvements:

• Ensure there is an effective, well-governed process to enable compliance with Patient Safety Alerts, recalls and rapid response reports.

There were areas of practice where the provider should make improvements:

• Continue reviewing and monitoring performance, including survey results; implementing systems and processes to improve the quality of services and establish systems to evaluate progress.

• Continue reviewing and monitoring quality performance to improve patient outcomes across areas of the local quality framework such as dementia care and asthma care. 

• Continue exploring effective ways of improving working relationships and joint working with the Patient Participation Group.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice