Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Maddock Way Surgery on 5 July 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 or sufficiently documented.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks and patient group directions.
• 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.
• All of the patients that we spoke to said they were treated with compassion, dignity and respect. However, the practice scored below national and local averages in the national GP patient survey.

• Information about services was available, but there was little information provided to patients about how to make a complaint.

• The practice had a number of policies and procedures to govern activity.
• Meetings at the practice were sparsely recorded and minutes did not detail what was discussed and by whom.

The areas where the provider must make improvements are:

• Ensure that the floor in the water damaged consulting room is repaired as soon as possible.

• Ensure that all staff have received mandatory training.

• Ensure that authorisations for repeat prescriptions are overseen by a clinician.

• Ensure that Patient Group Directions are in place for all areas of care and are signed by all appropriate staff.

• Ensure that the complaints process is advertised to patients and that details of all complaints are recorded.

In addition the provider should:

• Consider more formally documenting meetings to enable review and audit

• Consider adding details of all staff to the practice’s business continuity plan and keeping a copy of it available in case of an emergenccy.

• Review the national GP patient survey and consider actions to take to improve patient satisfaction where results were below national averages.

• Make suitable arrangements for translation and interpretation which respects the patient’s dignity and confidentiality.

• Consider putting a website in place to inform patients of services available.

• Consider including details of discussions from multi-disciplinary team meetings in patient notes.

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 Maddock Way Surgery on 5 July 2016. The overall rating for the practice was requires improvement. The full comprehensive report of the 5 July 2016 inspection can be found by selecting the ‘all reports’ link for Maddock Way Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 14 March 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 5 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

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Overall the practice is now rated as good.

Our key findings were as follows:

• The practice had clearly defined and embedded systems, processes and practices to minimise risks to patient safety.

• Staff demonstrated that they understood their responsibilities and all had received training on safeguarding children and vulnerable adults relevant to their role.

• Information about how to complain was available and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

We also reviewed the areas we identified where the provider should make improvement:

• The practice had adequate arrangements to respond to emergencies and major incidents.

• The practice had translation services in place.

• The practice had introduced a website which contained relevant information about the practice, and health promotion advice.

• Meetings at the practice were minuted and decisions were clearly recorded.

However, there was an area of practice where the provider needs to make improvements.

The provider should:

• Review the national patient survey where results were in some areas below national averages.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

We spoke with five people who used the service and they were all positive about the care and treatment they received. They included two representatives of the practice’s patient participation group who found the group helpful in keeping patients in touch with developments at the practice and in being able to provide feedback from patients about the service provided. One person we spoke with said, “I always feel listened to. The staff work well as a team and there is always a good atmosphere in the waiting area.” Another person told us, “I have been coming here a long time, the staff know me well and are polite and welcoming. Appointments are never rushed and the doctor always takes the time needed.”

People told us they felt involved in decisions about their care, were provided with clear information and understood the treatment and choices available.

Care was planned and delivered in way to ensure people’s safety and welfare. We saw up to date plans that set out people’s care and treatment needs, identified potential risks to their health and showed their agreement was sought in the care and treatment provided.

There were arrangements in place to deal with foreseeable emergencies. However, these arrangements may not ensure sufficiently people’s safety and welfare.

There were appropriate procedures in place to protect people from abuse and staff knew how to identify and report signs of abuse.

There were effective recruitment and selection processes in place and people were supported by, suitably qualified, skilled and experienced staff.

There were systems in place to monitor the quality of service provided. People who used the service gave feedback through patient surveys on service quality and delivery. The service had a patient participation group which provided support and advice to the practice on behalf of patients. The service had systems to manage and review incidents and complaints.