Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Herne Hill Group Practice on 19 October 2015. Overall the practice is rated as good.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.

• 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 (PPG).

• Risks to patients were assessed and well managed.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance. All staff had received training appropriate to their roles.

• There was evidence of audit cycles to show that audits were driving improvement in performance to improve patient outcomes; however some audits had not been completed.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.

• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day. Patients said they were not always given enough time during consultations, but we saw that the practice had taken steps to address this.

• The practice had good facilities and was well equipped to treat patients and meet their needs. Information about services and how to complain was available and easy to understand.

• The practice had a number of policies and procedures to govern activity, and these had been reviewed.

• The practice held regular multi-disciplinary, clinical and general governance meetings and learning shared at these meetings was documented.

• 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 practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet people’s needs. They received referrals from a local church and housing fellowship which ensured that people living in vulnerable circumstances were able to receive medical care to suit their needs.

• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice.

We saw several areas of outstanding practice:

• The practice provided and won innovation awards for a dedicated young people’s clinic where young people could receive health advice, counselling and treatment, including sexual health and mental health services regardless of whether they were registered at the practice or not. The practice was able to demonstrate the positive impact that the clinic had on young people who attended.

• The practice had a smoking cessation adviser to support smoking cessation and could demonstrate this had a positive impact for patients using this service. The adviser won an award from Lambeth borough council for having the highest quit rate in Lambeth.

• The practice ran virtual clinics for patients with long term health conditions and they could demonstrate these had reduced unplanned hospital admissions.

However there were areas of practice where the provider needs to make improvements.

The provider should:

• Ensure all staff who act as chaperones are familiar with the chaperoning procedure.

• Ensure annual appraisals are carried out for all staff and that appraisals are dated and signed.

• Consider carrying out practice patient surveys to continually monitor patient feedback.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice