Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection 14 October 2016 – Good)

The key questions are rated as:

Are services safe? – Good

We carried out an announced comprehensive inspection at Eden Court Medical Practice on 14 October 2016. The overall rating for the practice was good; however, the practice was rated as requires improvement for providing safe services. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Eden Court Medical Practice on our website at www.cqc.org.uk.

Following our October 2016 inspection, we asked the practice to send us a report that says what actions they were going to take to meet legal requirements. This inspection was a focused inspection carried out on 18 April 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 14 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At this inspection we found:

The practice had addressed all concerns that were identified at our previous inspections.

• 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.

• There was a strong focus on continuous learning and improvement at all levels of the organisation.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Eden Court Medical Practice on 14 October 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 among partners towards reporting significant events which had been thoroughly investigated and where patients had received an apology. However, we identified a lack of evidence to demonstrate effective sharing of learning among all staff.
• Risks to patients were not consistently well managed, we found weaknesses in the management of risks relating the premises (including fire and legionella). However, the practice has since undertaken fire and legionella risk assessments. The practice was also unable to demonstrate that issues arising from recruitment checks had been appropriately risk assessed.
• 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.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The national GP patient survey showed the practice among the highest in the West Midlands for patient satisfaction. For example, 100% of patients said they had confidence and trust in the last GP they saw. The practice was rated first in the CCG and tenth in the West Midlands as a result of survey feedback.
• The practice received few complaints. However, at the time of inspection information about how to complain was not easily accessible to patients. The practice told us that they had acted on this following the inspection.
• Patients said they found it easy to make an appointment with urgent appointments available the same day.
• The practice had good facilities and was well 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 was consistently positive.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Review systems for the routine identification and management of risks relating to the practice, patient and staff safety

The areas where the provider should make improvement are:

• Review systems for reporting all significant events and incidents and ensuring that learning is shared with all staff.
• Establish effective systems for monitoring the use of prescription stationery.
• Introduce systems for the routine checking of the oxygen available for use in an emergency.
• Ensure issues identified from recruitment checks are appropriately risk assessed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice