Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Healds Road Surgery on 7 January 2016. The practice was rated as requires improvement for providing safe services. The practice’s overall rating was good. A breach of legal requirements was found.

Following on from the inspection the practice provided us with an action plan detailing the evidence of the actions they had taken to meet the legal requirements in relation to providing safe services to their patients.

We undertook a desk based review on 29 August 2016 and visited the practice on 31 August 2016. This was to review in detail the information the practice had sent to us and to confirm that the practice were now meeting legal requirements. This report only covers our findings in relation to those legal requirements.

The full comprehensive report which followed the inspection in January 2016 can be found by selecting the 'all reports' link for Healds Road Surgery on our website at www.cqc.org.uk.

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

• Systems were in place to effectively manage the safe storage of vaccines.

• Staff had received training to ensure that the temperature of the vaccine fridges was recorded and staff understood that any temperatures outside of the accepted range for the storage of vaccines must be reported without delay

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 Healds Road Surgery on 7 January 2016. Overall the practice is rated as good.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• The practice did not have effective systems to ensure the vaccination fridge was monitored correctly. Past records of maximum temperature readings were consistently above the acceptable range for the storage of vaccines from January to June 2015.
• Risks to patients were assessed and well managed.
• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, the practice took a whole team approach to improving outcomes for patients.
• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.
• The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand.
• The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff who all had clear responsibilities in relation to the vision.

• 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. Information about services and how to complain was available and easy to understand.
• 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.

We saw one area of outstanding practice:

The practice had increased the uptake of cervical smears from 60% to 72% in the preceding 12 months by employing a bilingual nurse who audited patient uptake, identified barriers to attendance and created an action plan to remove them. As a result patients were actively encouraged to attend, the recall system and invitation letters were reviewed and evening appointments were offered.

The areas where the provider must make improvements are:

• Implement systems to effectively monitor the temperature of the vaccine fridge and take action where the temperature falls outside accepted range. Ensure the temperature of the vaccine fridge is calibrated at least every month against an independently powered external thermometer.

The areas where the provider should make improvements are:

• Ensure the practice has a system for production of Patient Specific Directions (PSDs) to enable Health Care Assistants to administer vaccinations
• Ensure information is available to complainants about how to take action if they are not satisfied with how the provider manages and/or responds to their complaint.
• Ensure there are systems and processes that assure compliance with statutory requirements and safety alerts.
• Ensure policies and procedures are up to date and in line with current legislation and guidance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice