Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection 19 May 2016 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced inspection at Fencepiece Road Medical Centre on 18 January 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014 as part of our inspection programme.

At this inspection we found:

• 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.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• 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 it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Consider introducing a system to record the actions and outcomes of MHRA and patient safety alerts.
• Review how carers are identified and recorded on the clinical system to ensure information, advice and support is made available to them and more carers are identified.
• Consider ways in which the uptake for cervical screening can be increased so as to bring it in line with the 80% coverage target for the national screening programme.
• Review the results from the July 2017 annual national GP patient survey and consider ways in which patients’ satisfaction as regards how they could access care and treatment could be increased so as to make it more comparable to national averages.

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 Fencepiece Road Medical Centre on 19 May 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 an effective system in place for reporting and recording significant events.
• Although risks to patients were assessed and well managed, the practice had not risk assessed the premises for fire or undertaken portable appliance testing. Shortly after the inspection the practice provided evidence that these had been carried out.
• 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.
• 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.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, 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 it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

• Put procedures in place to ensure Patient Group Directions are signed and available to the locum practice nurse administering vaccines.
• Ensure there is an effective system to track blank prescriptions through the practice in line with national guidance.
• Review how carers are identified and recorded on the clinical system to ensure information, advice and support is made available to them.
• Ensure portable appliance testing is undertaken at a frequency in line with guidance.
• Ensure any actions identified in the fire risk assessment are implemented.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice