Letter from the Chief Inspector of General Practice

This practice is rated as Good overall.

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 comprehensive inspection at Fryerns Medical Centre on 23 November 2017. We carried out a comprehensive inspection of this service 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

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to reoccur. Incidents that had been reported had been investigated. Lessons were learned and processes were improved.

• 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 which were discussed in clinical meetings.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Patients found the appointment system easy to use. However patient feedback said that it was difficult to get through on the telephone. The practice was looking at updating their telephone system to cope with demand.

• Appropriate recruitment checks were carried out and there were current registrations with their professional bodies where applicable.

• Staff had received mandatory training applicable to their role.

• There was sufficient and appropriate equipment for use in the treatment of patients, including in the event of a medical emergency and the equipment was calibrated to ensure it was working correctly.

• The practice had completed various risk assessments in relation to areas that were identified at risk. There were mitigating actions and levels of risk were assessed.

• There was a comprehensive business continuity plan in place in the event of an emergency taking place that disrupted the services to patients. The practice could relocate to the partners neighbouring practice if required.

• Boxes of prescriptions were stored securely however on the day of inspection were not tracked through the practice. The practice amended the monitoring sheet immediately and said that this would be implemented following the inspection.

• The practice sought and acted on feedback from staff, patients and had listened and responded to surveys completed. The practice had also completed its own survey with patients and planned to complete this quarterly to check changes made showed improvement.

• The practice did not have an active patient participation group. However there was an initial meeting planned for February 2018.

• The practice was clean and tidy and staff had reviewed infection prevention control and policies.

• Patient safety and medicine alerts were shared amongst the clinical team and consistently actioned and a record and log was maintained.

The areas where the provider should make improvements are:

• Implement the procedure to ensure prescriptions are tracked throughout the practice.

• Review the policies and procedures to ensure they are personalised and practice specific.

• Continue to work to establish a Patient Participation Group.

• Continue to seek and act on feedback from relevant persons and other persons on the services provided in the carrying on of the regulated activity, for the purposes of continually evaluating and improving such services. For example telephone access.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice