We carried out an announced comprehensive inspection at Broom Leys Surgery on 13 February 2019 as part of our inspection programme.

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information from the provider, patients, the public and other organisations.

We have rated this practice as good overall.

We rated the practice as good for providing a safe, effective caring and well led service. This was because:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We rated the practice as requires improvement for providing a responsive service and all population groups because:

The findings of the national GP patient survey indicated that patients could not always access care and treatment in a timely way. The practice had taken some steps to address this but at the time of our inspection there was insufficient data to measure the effectiveness.

The areas where the provider should make improvements are:

• Continue to monitor and improve patient satisfaction in respect of access to the service, in particular, the improvement of telephone access.
• Further improve the system for significant events to include reviewing events to ensure actions implemented are effective.
• Consider increasing the frequency of nurse meetings.
• Continue to monitor that weekly and monthly checks within the practice are being completed, for example in respect of fire safety and emergency equipment.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Broom Leys Surgery on 28 November 2017.

We carried out the inspection of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This practice is rated as Good.

The key questions are rated as:

Are services safe – Good

Are services effective – Good

Are services caring – Good

Are services responsive – Good

Are services well-led – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those retired and students –Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

At this inspection we found:

• The practice learned and made improvements when things went wrong. Systems were in place to enable staff to report and record significant events. Further work was required to ensure details of the investigation or what actions and learning had taken place were documented on each significant event form.

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

• The practice had a system in place to safeguard service users from abuse and improper treatment but on the day of the inspection some of the processes was not effective. Since the inspection the practice had completed a full review of its safeguarding processes and an action plan and supporting documents are now in place.

• Staff we spoke with 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.
• Feedback from people who use the service and stakeholders was positive. 23 patients expressed high levels of satisfaction about all aspects of the care and treatment they received. The feedback from comments cards we reviewed from patients told us that staff were welcoming, caring, courteous, friendly, understanding and professional.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Information about services and how to complain was available. 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.
• Quality improvement had been carried out but we saw limited evidence that demonstrated that audits were driving improvements to patient outcomes.
• There was a clear leadership structure and staff felt supported by management.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvements are:

• Establish and embed effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For example, significant events, safeguarding, NICE guidance, quality improvement including clinical audit.
• Complete the work required to ensure staff and patients are safe. For example, in regard to remedial actions for legionella. Advise the Care Quality Commission when the work has been completed.

The areas where the provider should make improvement are:

• Ensure the nurse practitioner has regular clinical supervision.
• Ensure learning from significant events and complaints are shared with staff.

• Explore how the patient satisfaction scores in relation to how patients could access care and treatment from the National Patient Survey can be improved.

• Ensure meeting minutes contain details of the discussions that have taken place and actions identified are completed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice