This practice is rated as Good overall. (Previous rating 15/12/2016 – Good overall)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Chichele Road Surgery on 26 June 2018. We carried out this inspection to follow up a breach of regulations identified at the previous inspection. At the previous inspection we found that patients’ privacy was not always protected at the reception desk and this was a breach of regulation 10.

At this inspection we found:

• The practice had improved patient privacy at the reception desk since our previous inspection.
• 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.
• Practice performance was below the local and national averages for cervical screening coverage; child immunisations and the management of diabetes and hypertension. The practice could not provide recent validated data to show improvement. This was an area identified for improvement at the previous inspection.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients reported that they were able to access care when they needed it. The practice operated a walk-in morning surgery which patients said was convenient. However, it resulted in regular queues outside the practice in the early morning.
• There was a focus on continuous learning and improvement at all levels of the organisation. The practice had addressed most of the areas for improvement identified at the previous inspection.
• There was a lack of clarity about the reasons for the practice’s below average performance of long-term conditions; immunisation and screening uptake rates and a lack of accessible information to assess current progress.

The areas where the provider must make improvements are:

• The practice must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. This includes the use of information to assess practice performance.

The areas where the provider should make improvements are:

• The practice should review its appointment system to ensure that patient queues are minimised and the risks have been assessed.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief 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

We carried out an announced comprehensive inspection at Chichele Road Surgery on 15 December 2016. 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 a system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Data showed patient outcomes were low compared to the national average for QOF.
• Although some audit and data collection had been carried out, there was no evidence that a programme of audits was being used to drive improvements to patient outcomes.
• Patients said they were treated with compassion and dignity, however not all felt that they were respected by staff. Not all patients felt that they were given enough time or information to make decisions about their treatment. This was not supported by the GP survey findings

• People told us that confidentiality was not always maintained at the reception desk, although there was a private room available for people to speak confidentially to staff.
• We also observed that it was possible to hear patients’ names and who they were seeing when receptionists were speaking on the telephone. All reasonable measures had not been taken to ensure confidentiality.

• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns, however the provider could not evidence how learning outcomes were shared with staff.
• The practice had facilities and was 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 improvement are:

• Implement further measures to improve patient confidentiality at the reception desk to ensure the privacy of people.

The areas where the provider should make improvement are:

• Review systems to identify carers in the practice to ensure they receive appropriate care and support.
• Consider improving communication with patients who have a hearing impairment and make people aware of translation services available to them.
• Continue to make improvements in the performance for QOF, including patient outcomes in long-term conditions, childhood immunisations and cervical screening programme to align with local and national averages.
• Review complaints systems to include recording and review of all complaints, verbal and written to improve services and share learning outcomes with staff and those involved.
• Develop an ongoing programme of audits to monitor and improve the quality of service being provided to people.
• Review and establish systems to manage uncollected prescriptions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Patients’ views and preferences were taken into account in the way the service was provided and delivered. The feedback from patients was largely positive. Patients told us they were involved in their care.

There was evidence to indicate that patients had been asked for their consent to the examination, care, treatment and support they received. Patients told us that they were given enough information to make decisions.

Patients' needs were assessed and their care and treatment were planned and delivered in line with their individual care plans. Key information relevant to patients’ care was recorded. This included a record of their medical history, allergy details and health status.

The practice had taken reasonable steps to identify the possibility of abuse. The practice had nominated lead staff for children and adult safeguarding. Staff were aware of what constituted abuse and how to raise a concern.

Patients who used the service and their representatives were asked for their views about their care and treatment and these were acted upon.

The provider had systems in place to regularly gather feedback from patients who used the service. We reviewed the records of some patients. In all cases we were satisfied that the practice had taken action to ensure patients’ records were accurate, fit for purpose and held securely.