Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Elm Practice on 19 January 2016. The overall rating for the practice was good. Within that overall rating the practice was rated as requires improvement for providing safe services. This was because it was not meeting some legal requirements in relation to using significant events to identify and learn from both good and poor practice. The full comprehensive report of the January 2016 inspection can be found at www.cqc.org.uk/location/1-2028308410.

This inspection on 15 June 2017 was an announced focused inspection and was carried out to confirm that the practice had completed their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 19 January 2016. This report covers our findings in relation to those requirements.

Overall the practice is rated as good.

Our key findings were as follows:

• The practice had put a system in place for recording significant events in a timely way and provided assurance that action was taken to prevent reoccurrence when something went wrong.

The practice had also acted on recommendations we made at our previous inspection and implemented additional improvements:

• A range of information about the practice was available in the five most prevalent languages spoken by people locally in addition to English: Hebrew, Polish, Spanish, Turkish and Urdu. Information included the practice leaflet, registration and the new patient questionnaire, and chaperone availability. Information about this resource and about the availability of interpreting services was on display in the reception area.

• The practice was implementing the NHS Accessible Information Standard. It was inviting patients to let staff know what their communication needs were, and it had added a question about communication needs to the new patient registration form. There was support for the practice from the local GP Federation to provide information in alternative formats.

• The practice had put in place a programme of regular infection control audits including a weekly checklist and a six-monthly more in-depth checklist. The last six-monthly audit was carried out on 12 April 2017 and we saw evidence that action was taken to address improvements identified as a result.
• The fire alarm was being tested weekly and a system was in place for the practice to have an annual fire drill. The last fire drill took place on 12 January 2017. The practice carried out a weekly fire safety audit, for example to check that all evacuation routes were free from any obstruction.

At our previous inspection on 19 January 2016 we rated the practice as requires improvement for providing safe services because significant events were not recorded in a timely way and there was no assurance that action was taken and that reoccurrence was prevented. At this inspection we found these shortfalls had been remedied. Consequently, the practice is rated as good for providing safe services.

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 Elm Practice on 19 January 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 but significant events were not being recorded as soon as they occurred and action plans were not always implemented following significant events.
• Risks to patients were assessed and well managed with the exception of those relating to fire safety and infection control.
• We saw two completed clinical audits driving improvement, however, we did not see evidence of a recent infection control audit.
• Information about services was available but not everybody would be able to understand or access it due to the diverse ethnic mix of the practice and the amount of patients requiring interpreters.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had 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 provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

• Provide practice information in appropriate languages and formats and ensure information about interpreter services is clearly displayed.
• Ensure they carry out internal infection control audits in line with national guidance.
• Ensure fire safety is carried out in line with fire safety policy.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice