Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Burdwood Surgery on 16 June 2015. Overall the practice is rated as good.

Specifically, we found the practice to require improvement for providing effective services. It was good for providing safe, caring and responsive services and for being well-led. These ratings also meant the practice was rated as good for providing services and meeting the needs of the six population groups.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety including incidents and complaints was recorded, investigated and acted on to ensure improvements to safety and effectiveness were made.
• Most risks to patients were assessed and well managed, including fire, medical concerns which may affect their care and the risks associated with storing medicines.
• Data showed patient care outcomes for patients were similar to the locality.
• Audits had been carried out, but out of seven current audits only three were repeated and completed. From the three completed audits we saw improvements to patient care were achieved. However, audit did not always lead to improvements in patient care due to the lack of re-auditing.
• 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.
• Availability of appointments for advanced and same day appointments was adequate to meet the needs of the local population. There was positive feedback from patients regarding appointments.
• The practice had a number of policies and procedures to govern activity. They were regularly updated and shared with staff.
• The practice held regular governance meetings and issues were also discussed at ad hoc meetings. All staff had opportunities to attend meetings and all practice staff met together twice a year.
• The practice had proactively sought feedback from staff and patients.
• The Patient Participation Group (PPG) had 122 members and there was a meeting four times a year. There was also a virtual group and which had 667 members.

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

The areas where the provider must make improvements are:

• Ensure staff are able to follow the principles of the Mental Capacity Act 2005.
• Review the clinical audit programme to ensure that audits lead to any changes in patient care where necessary.

The areas the provider should make improvements are:

• Provide the infection control lead with training of an appropriate standard.
• Advertise the translation service on the website.
• Undertake all actions noted from the legionella risk assessment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

On the day of our visit to Burdwood Surgery we met with the practice manager and one of the GPs. We spoke with seven patients and seven members of practice staff. We were unable to speak with the Patient Participation Group (PPG) Chair as they were unavailable on the day of inspection. Feedback questionnaires were sent to the PPG members and we received seven responses.

Patients were treated with dignity and respect. On the day of inspection we observed patients being addressed appropriately. Staff spoke with patients in a caring way. We found that the practice had considered the different cultural and diverse needs of patients. For example, the practice was fully accessible to all and there were translation services available.

All of the patients we spoke with were happy with the care and treatment they received. One patient said "I have been a patient here for 20 years and they always provide a great service". Another person said "I find the reception staff particularly caring and kind".

Patients were protected from the risk and spread of infection because appropriate guidance had been followed.

Patients were protected from the risks of abuse because the provider had ensured that staff had received all of the appropriate safeguarding training. The patients we spoke with told us that they felt comfortable when attending appointments and had no concerns about their safety.

Staff felt supported in their roles. We found that staff had received training and appraisals. One person told us "We are a very close team and the communication is excellent".

Patient views were sought and their responses were acted upon. The practice ensured appropriate management and processes were in place to protect the safety and welfare of their patients.

Letter from the Chief Inspector of General Practice

In June 2015 we found concerns related to clinical audits and implementation of the Mental Capacity Act 2005 during a comprehensive inspection of Burdwood surgery. Following the inspection the provider sent us an action plan detailing how they would make the required improvements.

We carried out a desktop review of Burdwood Surgery on 15 January 2016 to ensure these changes had been implemented and that the service was meeting regulations. Our previous inspection in June 2015 had found a breach of regulations relating to the effective delivery of services. The ratings for the practice have been updated to reflect our findings.

We found the practice had made improvements since our last inspection on 16 June 2015 and they were meeting the regulation relating to clinical audits and Mental Capacity Act 2005 that had previously been breached.

Specifically the practice had:

• Implemented a programme of clinical audits and re-audits to improve patient outcomes.

• Ensured Mental Capacity Act (2005) training was provided for key personnel in the practice.

We have changed the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well led services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice