Highfield Surgery in Leicester is a Doctors/GP specialising in the provision of services relating to diagnostic and screening procedures, family planning services, maternity and midwifery services, services for everyone, surgical procedures and treatment of disease, disorder or injury. The last inspection date here was 7th February 2017
Highfield Surgery is managed by Highfield Surgery.
Contact Details:
Address:
Highfield Surgery 25 Severn Street Leicester LE2 0NN United Kingdom
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Highfield Surgery on 17 November 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
There was an effective system in place for reporting and recording significant events and lessons were shared to make sure action was taken to improve safety in the practice.
There was a system in place to review and action MHRA alerts, however we noted not all alerts from the Department of Health were actioned accordingly. For example, estates and facilities alerts.
The practice had systems, processes and practices in place to keep patients safe and safeguarded from abuse.
There was a system in place to monitor the use of prescription forms, but not prescription pads.
Most risks to patients were assessed and managed. However, not all identified actions were carried out.
Staff assessed needs and delivered care in line with current evidence based guidance. Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were above average compared to the national average in several areas.
Staff had the skills, knowledge and experience to deliver effective care and treatment.
There was evidence of appraisals for all staff.
Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.
Staff were aware of their responsibilities in relation to the Mental Capacity Act and had undergone training.
The practice promoted health education and self-management of medical conditions for patients to live a healthier lifestyle.
Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care.
Information for patients about the services available was easy to understand and accessible.
We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.
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 and evidence showed the practice responded quickly to issues raised.
The practice had a vision to deliver quality care and promote good outcomes for patients, within a family practice environment.
There was a leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity.
There was a governance framework which supported the delivery of the strategy and good quality care.
The practice sought feedback from staff and patients, which it acted on.
The areas where the provider should make improvement are:
Document the flushing of the taps and water temperatures.
Review the monitoring system of prescription pads.
Review all alerts and ensure action is taken as appropriate.
Letter from the Chief Inspector of General Practice
We carried out an announced follow up inspection of Highfield Surgery, 25 Severn Street, Leicester, Leicestershire, LE2 0NN on 17 December 2015.
Our previous inspection in April 2015 had found breaches of regulations relating to safe delivery of services and services being well-led.
We found the practice had made improvements since our last inspection in April 2015. Specifically the practice was:
There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
Process of reviewing and learning of incidents following were not documented with actions and action owners.
A ramp had been erected at the back door to evacuate patients with reduced mobility in the event of a fire.
Information about services and how to complain was available and easy to understand but only available in English.
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 had an approved set of Patient Group Directives to allow specified staff to administer a medicine directly to patients without the need for a prescription.
Processes and procedures had been reviewed and were stored in a central place on the desktop of all computers in the practice.
Staff following processes, such as fridge checks were not aware of what to do if there was a problem.
Nurses did not have protocols to follow for example raised blood pressure.
Recruitment checks such as DBS had taken place or been applied for in relation to new staff members.
The areas where the provider should make improvement are:
Ensure that staff have a formal annual appraisal.
Have a system in place to ensure audit cycles have been completed.
Practice meetings to include items such as, significant events, complaints, risk management, infection control and NICE guidance. Clinical meetings should be minuted in order to record summaries of topics discussed and actions to be taken.
Ensure staff have appropriate policies, protocols and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice and that the staff understand them.
Ensure there is a robust system to manage and learn from significant events, near misses and complaints.
We have changed the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe services and requires improvement for the provision of well-led services. The practice had been rated as good for the provision of effective, caring and responsive services.
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Highfields Surgery – S R Choudhary on 8 April 2015. Overall the practice is rated as requires improvement.
Specifically, we found the practice to require improvement for providing safe and well led services. It also required improvement for providing services for all the population groups. It was good for providing an effective, caring and responsive service.
Our key findings across all the areas we inspected were as follows:
There was not a clear system for reporting incidents, near misses or concerns, therefore evidence of learning and communication to staff was limited.
Risks to patients were not assessed and well managed.
Data showed patient outcomes were average for the locality. Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
Patients felt that the quality of care was good. They felt respected, well looked after and staff were kind and considerate.
94% patients who responded to the national patient survey said they had confidence and trust in the last GP they saw.
Urgent appointments were usually available on the day they were requested.
The practice had a number of policies and procedures to govern activity, but some were still in the name of the previous practice manager and required reviewing and updating.
The practice had not proactively sought feedback from staff or patients.
The areas where the provider must make improvements are:
Ensure there is a robust system to manage and learn from significant events, near misses and complaints.
Identify, assess and manage risks relating to the health, welfare and safety of patients, staff and other people who may be at risk within the practice. For example, risk assessments for, health and safety, legionella, general office environment, disclosure and barring (DBS) and control of substances hazardous to health (COSHH), infection control and fire safety.
Ensure temporary ramp to back fire door is in place so that patients with reduced mobility can be evacuated in the event of a fire. This needs to be in place until building improvements have been finalised and implemented.
Provide staff with guidance to ensure that fridges are kept at the required temperatures, and describe the action to take in the event of a potential failure. Staff should reset fridge temperature control after daily readings have been taken.
Ensure that the practice have an approved set of Patient Group Directives to allow specified staff to administer a medicine directly to a patients without the need for a prescription.
Ensure the practice has a robust system in place for infection prevention and control, for example, effective cleaning schedules, audits of cleaning standards, information relating to the control of substances hazardous to health (COSHH) and product safety data sheets and ensure that the cleaner has sufficient cleaning products available.
Ensure that patient surveys prompt the delivery of improvement.
In addition the provider should:
Ensure that staff have appropriate support, identified through a formal appraisal system to have the necessary training to enable them to deliver the care and work they carry out in the practice.
For example, consent, fire, infection control, chaperone, Gillick competencies and Mental Capacity Act 2005.
Improve its recruitment arrangements and ensure necessary employment checks are in place for all staff.
Ensure that all equipment is regularly PAT tested and a schedule of testing is in place.
Ensure that the practice had a checklist for emergency equipment and it is checked regularly as per practice policy.
Have a system in place to ensure audit cycles have been completed.
Have a robust system in place to track prescription pads.
The practice should have practice meetings which are regular, structured and relevant to give all staff the opportunity to take part, where information is shared and lessons learnt. For example, significant events, complaints, risk management, infection control and NICE guidance. Meetings should be minuted in order to record summaries of topics discussed and actions to be taken.
Make PPG minutes available for patients to see in the waiting room and on the practice website.
Ensure staff have appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
Embed the complaints process to ensure that themes and trends are identified and lessons are learnt.
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Highfield Surgery on 17 November 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
There was an effective system in place for reporting and recording significant events and lessons were shared to make sure action was taken to improve safety in the practice.
There was a system in place to review and action MHRA alerts, however we noted not all alerts from the Department of Health were actioned accordingly. For example, estates and facilities alerts.
The practice had systems, processes and practices in place to keep patients safe and safeguarded from abuse.
There was a system in place to monitor the use of prescription forms, but not prescription pads.
Most risks to patients were assessed and managed. However, not all identified actions were carried out.
Staff assessed needs and delivered care in line with current evidence based guidance. Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were above average compared to the national average in several areas.
Staff had the skills, knowledge and experience to deliver effective care and treatment.
There was evidence of appraisals for all staff.
Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.
Staff were aware of their responsibilities in relation to the Mental Capacity Act and had undergone training.
The practice promoted health education and self-management of medical conditions for patients to live a healthier lifestyle.
Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care.
Information for patients about the services available was easy to understand and accessible.
We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.
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 and evidence showed the practice responded quickly to issues raised.
The practice had a vision to deliver quality care and promote good outcomes for patients, within a family practice environment.
There was a leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity.
There was a governance framework which supported the delivery of the strategy and good quality care.
The practice sought feedback from staff and patients, which it acted on.
The areas where the provider should make improvement are:
Document the flushing of the taps and water temperatures.
Review the monitoring system of prescription pads.
Review all alerts and ensure action is taken as appropriate.
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