Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pitsmoor Surgery on 18 May 2016. Overall the practice is rated as good.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Opportunities for learning from internal and external incidents were in place.
• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, the practice is an Advanced Training Hub working in collaboration with Sheffield Hallam University in the training and development of student nurses. The practice is also part of a neighbourhood working pilot in conjunction with the local Intermediate Care team to improve and develop access to services for patients living in the local community.
• Feedback from patients about their care was consistently positive.
• 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 participation group. For example, the design of the front reception area was changed to ensure patient confidentiality; disabled parking spaces were allocated and clearly marked at the front of the surgery to ensure ease of access and patients were involved in the interview and selection of new practice staff.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice actively reviewed complaints and how they are managed and responded to, and made improvements as a result.
• The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.
• The practice had strong and visible clinical and managerial leadership and governance arrangements.

We saw three areas of outstanding practice including;

• The practice rate of severe mental illness is three times above the city average and in response, the practice had been supporting a Primary Mental Health Care Project for over 20 years. This initiative provides enhanced care to patients with severe and enduring mental health needs who do not engage with other services. The project is run by staff with diverse professional backgrounds within the team who offer person centered care to improve the quality of life for people suffering with poor mental health. Individual and group work approaches are offered to these patients to reduce social isolation, increase self esteem and encourage them to participate in specific activities such as theatre trips, photography classes, singing clubs and chairobics.

• SAGE Greenfingers is a registered charity which developed in partnership with Pitsmoor surgery.  It is a horticultural therapy project to improve mental health through gardening for patients with severe and enduring mental health needs. The project offers patients the time and space to unwind, the opportunity to make new friends with organised transport and interpreters if needed.  The practice has allocated five dedicated allotments for use by this group of patients.

• 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. For example, the practice provided Roma Slovak services in direct response to the demographic needs of the local population (12% of the patient population are Slovakian).  This service offers patients; weekly booked surgeries with interpreters, dedicated new patient checks each Thursday, the promotion of community events including language classes, Hepatitis B screening including contact tracing and liaison with local schools and the Multi-Agency Support Team (MAST).  

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During our inspection we spoke with eight people using the service and various members of staff including the practice manager, the GPs, the nursing staff, reception and administrative staff. We met with the chair of the patient participation group (PPG). We also looked at staff files.

People that we spoke with were positive about the practice and the staff. Some comments included “They are very good with children and see them quickly”, “I feel really supported by the nurses” and “They ask questions but in a good way and we are seen promptly”.

All the people spoken with told us that they felt comfortable whilst being examined by the clinical staff and did not have any concerns.

We found that there were effective systems in place to reduce the risk and spread of infection. We saw that the practice was well organised and clean and tidy. One person told us, “It’s always spick and span here. They always wear uniforms and gloves too”.

All the staff spoken with told us that they enjoyed working at the practice and that they could ask for support when they needed to.

We found effective systems were in place to regularly assess and monitor the quality of service that people had received.