Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection March 2017 – Requires improvement)

The key questions are rated as:

Are services safe? – Requires Improvement

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) – Requires improvement

We carried out an announced comprehensive inspection at Irlam Group Practice on 1 December 2017 as a follow up to the previous inspection on the 27 March 2017.

At this inspection we found:

• The practice had made some improvements to their systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• 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.
• The practice now had a system in place to monitor their Quality and Outcomes Framework (QOF), and although there were still low scores for some of the indicators, the practice was working towards achieving improved results.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider Must make improvements are:

The provider must do all that is reasonably practicable to mitigate risks to the health and safety of service users receiving care and treatment. For example, the provider must ensure a DBS check is in place before clinical staff start employment.

The areas where the provider should make improvements are:

• Care plans should be more detailed to provide effective care.
• The complaints policy should be updated to reflect best practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

On 27 March 2017 we carried out a full comprehensive inspection of Irlam Group Practice. This resulted in a Warning Notices being issued against the provider on 12 May 2017. The Notices advised the provider that the practice was failing to meet the required standards relating to Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014, Good governance. A copy of this report can be found on our website: www.cqc.org.uk/search/services/doctors-gps

On 25 September 2017 we undertook a focused inspection to check that the practice had met the requirements of the Warning Notices. At this inspection we found that some improvement had been made and some systems had been introduced but further improvements were still required to ensure that safety was maintained. In particular we found that :

• The practice now had a system in place to receive and disseminate patient safety and medicine alerts. However we found that there were still some improvements to be made to this system to ensure alerts were dealt with in a timely manner.
• Clinical staff were now aware of relevant clinical guidelines and these were being discussed at team meetings.
• The system for safeguarding had been improved and there was a process in place to follow up appointments for children that did not attend.
• Staff members told us they felt there was an improvement in communication between the partners and practice staff members. Team meetings were now regularly occurring.
• The practice had a system for audit in place and we were shown two clinical audits that demonstrated quality improvement.
• The practice had arranged for a legionella risk assessment to be performed and was carrying out the recommendations as instructed.
• The system for complaints had been improved and the practice had ensured all complaints had been responded to.

The rating awarded to the practice following our full comprehensive inspection 27 March 2017 of ‘requires improvement’ remains unchanged. The practice will be re-inspected in relation to their rating in the future.

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 Irlam Group Practice on 27 January 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 27 January 2016 inspection can be found by selecting the ‘all reports’ link for Irlam Group Practice on our website at www.cqc.org.uk.

This inspection was undertaken as an announced comprehensive inspection on 27 March 2017. Overall the practice is still rated as requires improvement.

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

• The practice did not have a robust governance system in place and staff were not always aware of their own responsibilities.
• Data showed patient outcomes were low compared to the national average. Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.
• The practice had a number of policies and procedures to govern activity, but were not always accessible to staff.
• The service did not have a system in place to ensure patient safety and medicine alerts were acted on and disseminated to staff.
• Clinical staff were not always aware of their own safeguarding responsibilities within the practice.
• We found that patients who complained did not always receive a response.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.

The areas where the provider must make improvements are:

• Systems and processes must be established and operated effectively to ensure governance is in place.
• The service must ensure that information requested by the Commission is sent in a timely manner.
• Safeguarding systems and processes must be established and operated effectively.
• The service must monitor and improve the quality and safety of the service provided.
• The service must establish and operate effectively a system for responding to complaints.

In addition the provider should:

• Signed contracts for all staff should be available in recruitment files.
• Clinicians should have access to updates and alerts that may be sent via email.
• The practice should identify more patients who are carers

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 Irlam Group Practice on 27 January 2016. Overall the practice is rated as requires improvement.

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. However, reviews and investigations were not thorough enough.
• Most risks to patients were assessed and well managed.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Urgent appointments were available on the day they were requested but some patients told us it could sometimes be difficult getting an urgent appointment.
• The practice had a number of policies and procedures to govern activity, but some were incomplete and overdue a review.

The areas where the provider must make improvements are:

• Ensure all emergency medicines and other clinical consumables are in date.
• Ensure that the calibration of equipment is performed as per the manufacturers recommendations and that there is a system in place to identify when this needs to be performed.
• Ensure effective recruitment checks and induction arrangements are in place for all staff.
• Ensure the practice has an up to date business continuity plan and all staff are familiar with its contents.
• Ensure there are effective governance systems in place to identify and manage risks in order to protect service users and practice staff (by ensuring all risk assessments are in place such control of substances hazardous to health, fire safety and legionella).

In addition the provider should:

• Review the infection control policy to ensure that it is sufficiently detailed and specific to the needs of the practice.
• Review the fire risk assessment policy and ensure that it is up to date.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Irlam Group Practice on 1 December 2017. The overall rating for the practice was good with safe as requires improvement. The full comprehensive report on the December 2017 inspection can be found by selecting the ‘all reports’ link for Irlam Group Practice on our website at .

This inspection was an announced focused inspection carried out on 18 May 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 1 December 2017. In addition to the breaches, we identified an area where the practice should make improvements. This report covers our findings in relation to those requirements and also the additional improvements made since our last inspection.

Overall the practice remains rated as Good and ‘safe’ is now also rated as Good.

Our key findings were as follows:

• The practice ensured that pre-employment checks were carried out on new staff members which included Disclosure and Baring Service (DBS) checks for clinical staff.

The areas where the provider should make improvements are:

• Update the recruitment policy to include the pre-employment check list.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice