This practice was previously inspected in October 2017 and rated as Requires improvement overall.

This practice is now rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Baldwins Lane Surgery on 4 July 2018 to follow up on breaches of regulations we identified during our previous inspection in October 2017.

At this inspection we found:

• The practice had taken appropriate action following our previous inspection in October 2017 to ensure they were complying with regulations where we had previously identified breaches.
• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels.

We saw one area of outstanding practice:

The practice had discussed as a team they would like to improve their numbers of patients attending screening for Abdominal aortic aneurysm (AAA). The practice invited all male patients registered with them, over the age of 65, who had previously not been invited, or had been invited and not attended, for screening of Abdominal aortic aneurysm (AAA). In total the practice invited 228 male patients to attend. Of the patients invited, 79 attended and five were diagnosed with an abnormal aorta. All identified patients were followed up appropriately. The practice was contacted by the screening team at a local NHS trust and asked if they would share the letter they had used to invite patients as it was felt that other GP practices who struggled with patients attending screening appointments would benefit from using the letter.

The areas where the provider should make improvements are:

• The provider should ensure all actions from their fire risk assessment are completed as planned.
• The provider should continue to improve processes to ensure all safety checks are documented in line with practice policies and procedures.
• The provider should ensure all relevant staff are aware of the practice’s policy for patient specific directives, and take action to ensure it is adhered to and operated effectively when a healthcare assistant is employed.
• The provider should continue to take action to improve uptake of children’s’ vaccinations.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety. For example, the practice had arrangements for responding to non-medical major incidents. However, the practice had not considered the appropriateness’ of the storage of emergency medicines and equipment ensuring they were easily accessible in an emergency.
• 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. However, there were areas of medicine management, which did not provide assurance that blood monitoring results were reviewed prior to generating repeat prescriptions.

• Data from the Quality and Outcomes Framework showed patient outcomes were comparable to the local and national average. However, exception reporting (the removal of patients from QOF calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects) for some clinical domains were above average. Staff we spoke with were aware of this and were taking action to increase patient engagement.

• There were evidence of some quality improvement activities such as clinical audits, which demonstrated areas where improvements had been achieved.

• Results from the national GP patient survey showed a mixture of below and comparable local and national average results in patients’ satisfaction regarding feelings of being treated with compassion, dignity and respect and being involved in their care and decisions about their treatment. The practice was aware of these results; however, were unable to demonstrate they had started any actions to improve patient satisfaction.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• 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. The practice worked closely with neighbouring practices to provide more services to their patient population.
• The practice had adequate facilities and was well equipped to treat patients and meet their needs. However, some areas of the practice were not easily accessible to patients using a wheelchair.
• There was a clear leadership structure and staff felt supported by management.
• The practice had clinical and managerial leadership and governance arrangements. However, oversight of some governance arrangements such as management of medicines, some risks; monitoring training needs and actions to improve patient satisfaction was not effective.

The areas where the provider must make improvement are:

• Ensure care and treatment is provided in a safe way to patients.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

• Ensure persons employed in the provision of the regulated activity receive the appropriate training necessary to enable them to carry out the duties.

The areas where the provider should make improvement are:

• Ensure effective oversight of governance arrangements to ensure practice policies and processes are well embedded.

• Continue exploring and establishing effective methods to identify carers in order to provide further support where needed.

• Continue to review national GP patient survey results and internal patient feedback; explore effective ways to improve patient satisfaction. 

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice