Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lowmoor Road Surgery on 8 August 2016. The overall rating for the practice was good. The practice was requires improvement for providing safe services. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Lowmoor Road Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 7 February 2017 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 8 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key findings were as follows:

• There were appropriate systems in place to properly assess and mitigate against risks including risks associated with fire and managing emergency situations.

• A risk assessment had been completed with rationale documented for not ensuring a DBS check is in place for non-clinical members of staff.

• Ensure recruitment arrangements include all necessary employment checks for all staff

• Patients’ medical records were stored securely, the practice had a keypad lock on the door to were the records were stored.

• The practice had reviewed performance and monitoring of long term conditions and had actions in place to improve

• The practice had updated their registration of the practice to include all regulated activities.

The practice is now rated as good for providing safe services.

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 Lowmoor Road Surgery on 8 August 2016. Overall the practice is rated as good.

• There was an effective system in place for reporting and recording clinical significant events however non clinical events were not recorded.

• Lessons learnt were recorded as a result of incidents and discussed at practice meetings.

• The practice was visibly clean, however there was no schedule of completed cleaning available on the day of inspection.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

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

• We observed staff members were courteous and very helpful to patients and treated them with dignity and respect.

• Feedback from residential homes was positive and staff at the care homes said that the practice were responsive and always attended when required.

• The practice offered extended hours on a Saturday for working patients who could not attend during normal opening hours.

• Lessons were learnt from complaints and discussed with staff however information on how to complain was not readily available.

• There was a leadership structure in place. Staff told us they felt supported by management.

• The practice had a governance framework which supported the delivery of the strategy and quality care. However, we found some of the policies needed updating to reflect recent staff changes

• The provider was aware of and complied with the requirements of the duty of candour.

• The practice encouraged and valued feedback from patients, the public and staff.

• There was a focus on continuous learning and improvement at all levels.

• Monitoring of some long term conditions and excepting those that were not eligible needed attention.

• The practice worked in collaboration with eight local practices (also referred to as JAKS federation) to improve access for patients with a weekly walk in service for patients on Wednesday (6.30pm to 8pm) and Saturday (9am and 12pm). This service was accessible to all patients registered with the eight local practices.

The areas where the provider must make improvement are:

• Ensure that there are appropriate systems in place to properly assess and mitigate against risks including risks associated with fire and managing emergency situations.

• Ensure a risk assessment is carried out and rationale documented for not ensuring a DBS check is in place for non-clinical members of staff.

• Ensure recruitment arrangements include all necessary employment checks for all staff

• Ensure patients’ medical records are stored securely at all times.

• Ensure the registration of the practice is updated to include all regulated activities.

The areas where the provider should make improvement are:

• Review performance and monitoring of long term conditions.

• Improve the identification of carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice