Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Jedrzejewski and partners on 28 July 2015. The overall rating for the practice was requires improvement. Specifically it was good for providing effective, responsive and caring services but required improvement for providing safe and well led.

The full comprehensive report on the 28 July 2015 inspection can be found by selecting the ‘all reports’ link for Dr Jedrzejewski and partners on our website at www.cqc.org.uk.

The areas where the provider must make improvement were:

• Ensure a systematic approach to reporting, recording and monitoring significant events, incidents and accidents.

• Ensure there are formal governance arrangements and staff are aware how these operate, including maintaining the cleanliness and fabric of the building.

The areas where the provider should make improvement were:

• Review staff training to link this to personal development plans and practice’s needs.

• Review staff files to ensure that all contain the required.

This inspection was an announced comprehensive inspection carried out on 30 May 2017 to confirm that the provider 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 28 July 2015. This report covers our findings in relation to those requirements. We found that the concerns identified at the previous inspection had been rectified. Overall the practice is rated as good.

Our key findings were as follows:

• There was an open and transparent approach to safety and a system for reporting and recording significant events.

• The practice had clearly defined and embedded systems to minimise risks to patient safety.

• 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 and decisions about their treatment.

• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.

• 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.

• 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 the requirements of the duty of candour.

The area where the provider should make improvements is:

• The practice should review the provision of health checks for learning disability patients to help ensure that these are offered annually.

• Review the new protocol for managing medicines alerts to ensure it is effective.

• Should continue to develop systems for support patients who are caring for others.

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 Dr Jedrzejewski and partners on 28 July 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to be good for providing, effective, caring and responsive services. It required improvement for providing safe and well led services. The concerns that led to the practice requiring improvement for providing safe and well-led services applied to all the population groups. Therefore the practice requires improvement for the care of older people, people with long term conditions, for providing services to families, children and young people, working-age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

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

• Most staff understood and fulfilled their responsibilities to raise concerns, however some reporting of incidents and near misses did not take place. Evidence of learning from incidents was limited.
• Risks to individual patients were assessed and well managed but there was no systematic approach to clinical governance within the practice.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance.
• In some areas staff had received training appropriate to their roles. The practice had identified other areas where training had not been kept current and was addressing this.

• Patients said 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.
• Patients said they found it easy to make an appointment with a named GP and that 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.
• There was a clear leadership structure and staff felt supported by management. Evidence of governance was limited as was evidence of communication across the practice. There were departmental meetings but no forum or other mechanism to share learning and direction across the whole practice.

There were areas of practice where the provider needs to make improvements.

Importantly the provider must:

• Ensure a systematic approach to reporting, recording and monitoring significant events, incidents and accidents.
• Ensure there are formal governance arrangements in place and staff are aware how these operate, including maintaining the cleanliness and fabric of the building.

In addition the provider should:

• Review staff training to link this to personal development plans and practice’s needs.
• Review staff files to ensure that all contain the required information

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice