Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hazeldene House Surgery on 19 September 2016. Overall the practice is rated as good.

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

• Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

• Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients.

• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

• The practice had good facilities and was equipped to treat patients and meet their needs.

• The practice had fully effective standard operating procedures and systems in the dispensary to govern dispensing activities.

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. However, outcomes of significant events had not been shared with all staff or regular reviews carried out to identify trends.

• Information about how to complain was not readily available although patients we spoke with told us they had not had cause to complain. Verbal complaints had not been documented to help identify any common trends.

• Some arrangements were in place to ensure risks to patients were identified and managed.

• 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.

• Most patients said they found it easy to make an appointment with urgent appointments available on the same day.
• The provider was aware of and complied with the duty of candour.

The areas where the practice should make improvements are:

• Ensure outcomes of significant events are shared with all staff and carry out a regular analysis to identify any common trends, maximise learning and help mitigate further errors.

• Ensure all risks to patients and staff are assessed and identified actions completed and the health and safety lead be provided with additional training appropriate to the role.

• Ensure actions stated in the infection prevention control audit are completed or planned.

• Record verbal complaints to enable trends to be identified.

• Carry out health screening on new members of staff.

• Review the competency of dispensing staff as part of their annual appraisal.

• Consider increasing the number of nurse meetings held.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice