Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Moseley Avenue Surgery on 26 July 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the Month Year inspection can be found by selecting the ‘all reports’ link for Moseley Avenue Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 22 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 26 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings for this inspection were as follows:

The provider had made improvements:

• The practice had reviewed their policies and procedures and we saw evidence of this. During our inspection we spoke with staff to confirm that these had been shared and were available to all staff at the practice.

• The practice had carried out a number of risk assessments to ensure that the risks to staff and patients had been assessed and appropriately managed, for example, infection control audit and fire risk assessments.

• Systems had been put in place to ensure that all medical devices such as swabs were checked routinely by a nominated member of the nursing staff. We saw records had been maintained to confirm this.

The provider had also addressed the areas where we made recommendations that improvements should be made and we saw evidence to demonstrate this. These are included in the body of the report.

Work was ongoing regarding carers and the practice had plans to develop better awareness of the need to identify carers. For example, they had plans to liaise with Coventry Carers Association to attend the practice and raise awareness and were exploring the possibility of a future drop in session as well as seeking training for reception staff regarding carers. The practice had increased the number of carers from 52 to 187, which represented 1.7% of the practice population and introduced a section in the registration form for patients to highlight if they were a carer. Staff we spoke with were aware of the need to identify 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 Moseley Avenue Surgery on 26 July 2016. Overall the practice is rated as requires improvement.

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

• There was an open and transparent approach to safety but the practice did not have comprehensive systems to always assess and identify risks to safety. There was an effective system in place for reporting and recording significant events and evidence that the practice learned from them.
• Not all risks to patients were assessed and well managed for example, there was no recent health and safety risk assessment, fire risk assessment or fire drill.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Clinical staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment, although there was little evidence of training and development of non-clinical staff. For example, in safeguarding, infection control or information governance.
• The level of patient satisfaction was high. Patients we spoke with told us they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. The National GP Patient Survey results published in July 2016 were above the Clinical Commissioning Group (CCG) and national averages in all areas. Written comments received also aligned with these views.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Access to services offered was good. Patients said they found it easy to make an appointment and there was continuity of care, with urgent appointments available the same day.
• 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 sought feedback from staff and patients and staff reported that communication was good.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Ensure that all policies are developed, shared with staff, embedded and made readily available to staff in the practice.
• Ensure systems designed to assess the risk of and to prevent and control the spread of infection are implemented effectively. This would include taking actions identified as necessary by audits or risk assessments.
• Introduce a system to ensure that all medical devices are in date such as medical specimen swabs.

The areas where the provide should make improvements are:

• Consider introducing ways of increasing the number of carers identified.
• Introduce a system of notifying GPs when prescriptions have not been collected before disposal.
• Ensure risk assessments are regularly reviewed for all areas and aspects of the practice, for example health and safety and fire.
• Ensure that non-clinical staff receive regular refresher training in areas relevant to their roles such as safeguarding, infection control, fire training and information governance.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice