Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pembroke Road Surgery on 19 January 2016. Overall the practice is rated as good with outstanding features.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

• Feedback from patients about their care was consistently and strongly positive.

• The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient reference group (PRG). For example, they had introduced at the suggestion of the PRG, a ‘next step’ card which informed patients, who required further intervention after their initial consultation, what was happening subsequently.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that 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. For example, when a nearby practice had closed at short notice, patients receiving treatment for substance misuse, were transferred to the Pembroke Road Surgery where they were accommodated and treated on the same day. This meant there were no delays or interruptions in treatment for the patients.

• There was a clear leadership structure and staff felt supported by management.

We saw some areas of outstanding practice:

• The practice ran a series of pilot ‘Memory Cafes’ and invited patients living with dementia and their carers to the practice where the waiting room was turned in to a café for were refreshments. Patients living with dementia were engaged in ‘fun’ mental agility exercises, and education sessions were available for carers. The impact for the patients was being integrated into the practice, education about dementia for both a social and medical stance and the development of informal support networks for patients and carers.

• There was a Volunteers Group at the practice which helped patients with transport to and from the practice and hospital appointments. The members worked with the practice to offer a befriending service for lonely or isolated patients who could benefit from someone visiting them regularly at home or in hospital.

• The practice ran two ‘Pulmonary Rehabilitation’ courses in conjunction with the local community health partnership. The courses were two programmes for six weeks with two hours sessions of exercise and education held twice weekly. This was held in the waiting room at the practice as there were no public facilities available. The impact on patients was measured by the improvements in the four areas of the Chronic Respiratory Disease Questionnaire and improvements in patients’ shuttle walking test. For example, patients were less reliant on walking aids and had continued with the exercises outside of the practice organised courses.

The areas where the provider should make improvement are:

• The practice should ensure all personnel files have the information as required by regulation.

• The practice should review the prescription security protocol to ensure there was an audit trail in the event of any security incident

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice