Letter from the Chief Inspector of General Practice

The practice is rated good overall and good for providing safe services.

We carried out an announced comprehensive inspection of this practice on 17 November 2015. The overall rating for the practice was good. However, a breach of legal requirements was found during that inspection within the safe domain. After the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the legal requirements. We conducted a focused inspection on 17 March 2017 to check that the provider had followed their action plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.

During our previous inspection on 17 November 2015 we found the following area where the practice must improve:

• Ensure that all GPs are trained to level three children’s safeguarding.

• Ensure that a fire risk assessment, regular drills and fire training for staff are all carried out.

Our previous report also highlighted the following areas where the practice should improve:

• Continue to improve the uptake of new patient and NHS health checks.
• Continue to improve patient recall and reviews for patients with a learning disability and those living with long term conditions.
• Build on the work to demonstrate quality improvement by increasing the number of full cycle audits conducted within the practice.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

During the inspection on 17 March 2017 we found:

• All clinical staff were now trained in children’s safeguarding level three.

• The practice conducted regular fire drills, fire training and fire risk assessments in accordance with practice policy.

We also found the following in relation to the areas where the practice should improve:

• The practice was taking steps to improve the uptake of new patient and NHS health checks within the practice. Patients were sent a letter inviting them to attend and reminders about their appointments by text.

• The practice was taking steps to improve patient recall and reviews for patients with a learning disability and those living with long term conditions. The Quality and Outcomes Framework (QOF) performance results for the practice in 2015/2016 were 97% (92% clinical commissioning group and 95% nationally) which was an increase from 85% in 2014/2015. (QOF is a system intended to improve the quality of general practice and reward good practice). The practice now had a policy in place to phone non-attenders which had improved uptake.

• The practice had increased the number of full cycle audits conducted within the practice and four full cycle audits had taken place over the last 12 months.

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 Albion Street Surgery on 17 November 2015. Overall the practice is rated as good.

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 with the exception of those relating to fire safety.
• 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.
• Data showed patient outcomes were mixed for the locality, however we saw that the practice had taken action to improve areas where performance fell below average.
• Although audits had been carried out and we saw some evidence that audits were driving improvement in performance to improve patient outcomes these were not always full cycle.
• Data showed that not all patients with a learning disability had received a care plan review.
• All patients on the unplanned admissions register had an up to date care plan in place.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice scored higher than average in most areas of the national GP patient survey.
• 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. 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 areas where the provider must make improvements are:

• Ensure that all GPs are trained to level 3 children’s safeguarding.

• Ensure that a fire risk assessment, regular drills and fire training for staff are all carried out.

In addition the provider should:

• Ensure that action continues to be taken to improve uptake of new patient and NHS health checks.
• Ensure that action continues to be taken to improve patient recall and reviews for patients with a learning disability, and those living with long term conditions.
• Ensure all audits are full cycle audits.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice