Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Severn Surgery on 05 October 2016. Overall the practice is rated as good.

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

• All staff members had received a DBS check and a new system was in place to ensure all staff members had a DBS check carried out every three years.

• Approriate recruitment checks had been carried out for new staff members and a checklist had been devised to ensure appropriate checks were completed before staff commenced employment.

• A new system had been implemented to ensure relevant staff renewed their professional registration on an annual basis, for instance with the Nursing and Midwifery Council or General Medical Council.

• Safety data sheets and risk assessments were in place for all control of substances hazardous to health (COSHH) products.

• A staff member had been trained to be the designated health and safety lead and a full fire and health and safety risk assessment had been carried out in August 2016 and an action plan was in place to address the areas identified as needing improvement.

• A clinical governance framework had been developed which identified specific leads for topics such as audits, clinical quality, mitigating risk and complaints.

• Meeting templates had been devised to ensure at the beginning of each meeting all actions agreed were discussed to ensure they had been completed or an update with regards to progress was provided.

• A detailed business plan was also in place which included the objectives for the practice and underpinned the practice vision.

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 Severn Surgery on 15 February 2016. Overall the practice is rated as requires improvement.

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

• There was a system in place for reporting and recording significant events and staff were aware how to report an incident.

• Staff were knowledgeable about the actions they would take if they had any safeguarding concerns.

• There were embedded systems in relation to obtaining, prescribing, recording, handling, storing and security of medicines.

• Not all staff acting as a chaperone had been risk assessed to ensure they were able to carry out the role or received a Disclosure and Barring Service (DBS) check, if appropriate.

• Not all appropriate recruitment checks have been carried out before staff members started employment, as well as the monitoring of ongoing professional registration status.

• Risk assessments and data sheets were not available for all control of substances hazardous to health (COSHH) products.

• The practice had templates set up on the patient record system which reflected best practice guidelines and support planning of patient care with specific long-term conditions.

• Clinical audits were carried out and improvements made to the service provision as a result.

• Staff had the skills, knowledge and experience to deliver effective care and treatment and there was evidence of appraisals and personal development plans for all staff.

• Unplanned admissions or readmissions were reviewed on a daily basis and care plans were altered, as necessary.

• Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs.

• Patients said they were treated with dignity and respect and they were involved in decisions about their care and treatment.

• We saw staff were polite and professional, they treated patients with kindness and respect, and maintained patient confidentiality.

• A GP partner attended locality meetings to assist with the review of the local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.

• Most patients told us they found it easy to make an appointment.

• Patients said there was continuity of care and were aware urgent appointments were available the same day, if needed.

• Information about how to complain was available in the patient waiting area. Learning from complaints had been identified and the practice manager was taking action around the main theme.

• There was no documented overarching governance framework to support the delivery of a strategy and good quality care. However, GP partners were aware of the need to improve record keeping and systems which monitored and outlined the vision for the practice.

• Practice specific policies were implemented and were available to all staff.

• A programme of clinical and internal audit was in place which was used to monitor quality and to make improvements.

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

• There was an active patient participation group which met on a regular basis. The practice acted on feedback from the group and also feedback from patients and staff.

• The provider was aware of and complied with the requirements of the Duty of Candour. The partners encouraged a culture of openness and honesty.

The areas where the provider must make improvements are:

• The practice must review it’s governance arrangements to ensure all systems and processed are in place to ensure risks are identified and managed, for example in relation to risk assessments and monitoring of professional registrations.

• Ensure all appropriate recruitment checks carried out before staff members start employment.

In addition the provider should:

• Ensure a strategy is in place to identify the practice vision to support good quality patient care.

• Consider carrying out an access audit to ensure all reasonable adjustments are made for all patients to access the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice