Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Coatham Surgery on 22 July 2015. Overall the practice is rated as good.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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

• Patients who used the service were kept safe and protected from avoidable harm. The building was well maintained and clean.

• All the patients we spoke with were positive about the care and treatment they received. Patients told us they were treated with dignity and respect and staff were caring, professional and helpful.

• There was good collaborative working between the practice and other health and social care agencies that ensured patients received the best outcomes. Clinical decisions followed best practice guidelines.

• The practice met with the local Clinical Commissioning Group (CCG) to discuss service performance and improvement issues.

• There were good governance and risk management measures in place. The leadership team were visible and staff we spoke with said they found them very approachable.

However there were areas of practice where the provider should make improvements

• Ensure all recruitment checks are carried out in line with the practice policy.
• Ensure all staff are up to date with mandatory training.
• Ensure the practice has a written strategy which outlines their vision and plans for the future.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as requires improvement overall. (Previous inspection July 2015 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Dr Summers and Zaman (The Coatham Surgery) on 10 May 2018. This was an announced fully comprehensive inspection undertaken as part of our routine inspection programme.

At this inspection we found:

• Patients who used the service were kept safe and protected from avoidable harm. The building was well maintained and clean.
• The practice had an effective system in place to monitor patients on high risk anti-rheumatic medicines.
• All the patients we spoke with were positive about the care and treatment they received. Patients told us they were treated with dignity and respect and staff were caring, professional and helpful.
• The practice had an outreach nurse whose role was dedicated to home-visiting patients with chronic diseases, to assess, review and treat.

The areas where the provider should make improvements are:

• Ensure all recruitment checks are carried out in line with the practice policy.
• Ensure all staff are up-to-date with mandatory training; including fire training, equality and diversity, and safeguarding.
• Introduce a clinical supervision policy and facilitate clinical supervision for clinicians.
• Keep Patient Group Directions (PGDs) up-to-date and accessible to all nurses. (The provider updated all out-of-date PGDs on the day after our inspection)
• Improve the system for incident reporting so that incidents are accurately recorded by individuals and shared with the team, to identify trends and improve lessons learned.
• Record safeguarding; concerns, advice sought, and referrals made, in a central matrix to improve the overarching governance of safeguarding activity.
• Bring all staff appraisals up-to-date and review them within a 12 month period.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice