This practice is rated as required Improvement overall. (Previous inspection February 2015 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those recently retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) - Requires Improvement

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However,

  assessments to mitigate risks in the absence of Disclosure and Barring Service (DBS) checks had not been carried out.

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.

• Data such as QOF exception reporting rates showed areas where exception reporting was above local averages. However, the practice was aware of areas where performance was below local and national averages; and taking steps to improve. For example, improving the uptake of cervical screening, childhood immunisations and maintaining up to date disease registers.

• Staff involved and treated patients with compassion, kindness, dignity and respect. Results from the July 2017 national GP patient survey showed that the practice scored above local and national averages in a number of areas. Completed Care Quality Commission comment cards were also positive about the services provided.

• Results from the national GP patient survey showed patients did not always find the appointment system easy to use and patients were not always able to access care when they needed it. However, completed CQC comment cards we received during our inspection were more positive.

• The practice took action to improve patient satisfaction; however, staff were unable to demonstrate whether actions carried out resulted in improvements in the experience of people accessing the service.

• The practice worked with community services to ensure that vulnerable groups in the community were not excluded from accessing quality care. For example, staff worked closely with a local service that provided support for people facing problems with drug and alcohol dependency. Over the past 12 months, 11% of patients engaged in a shared care programme successfully completed a community detox.

• There was some focus on continuous learning and improvement at all levels of the organisation. Staff we spoke with verbally described learning from complaints.

• In some areas, there were responsibilities, roles and systems of accountability to support governance and management arrangements. However, oversight of systems and processes to manage areas such as safety checks, the identification of trends following incidents; responding to performance issues, monitoring training needs and reducing some risks was not effective.

The areas where the provider must make improvements are:

• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Continue to review the health and safety risk assessments and areas for improving the building.

• Continue exploring measures to improve the uptake of cervical screening and childhood immunisations.

• Establish a process for analysing complaints in order to identify trends and continue exploring measures to improve patient satisfaction in areas such as access.

• Continue considering reasonable adjustments and arrangements to support patients who may need extra support to access the services, such as patients with physical impairments whilst awaiting relocation.

• Review mental health data to ensure clear understanding and reasons for high exception reporting.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Schoolacre Road Surgery also known as Schoolacre Surgery on 5 February 2015.

We have rated each section of our findings for each key area. We found that the practice provided a safe, effective, caring, responsive and well led service for the population it served. We rated the practice as good overall.

Our key findings were as follows:

• There were systems in place to maintain the health and safety of the practice.

• The practice had effective procedures in place that ensured care and treatment was delivered in line with appropriate standards. The practice was proactive in promoting good health.

• Patients were treated with dignity and respect. Patients spoke very positively of their experiences and of the care and treatment provided by staff.

• The practice provided services that reflected the needs of the patients. There were dedicated areas in the waiting room that offered information about support systems and groups.

• We found that the service was well led with well-established leadership roles and responsibilities with clear lines of accountability.

However, there were also areas of practice where the provider should make improvements.

The practice should:

• Record all incidents and share learning with all staff members.
• Confirm if legionella risk assessment had been conducted by the landlord of the building.
• Ensure staff members are aware of the lead(s) for safeguarding in the practice.
• The practice should consider conducting criminal record checks for existing clinical staff and those that carry out the role of a chaperone.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice