This practice is rated as Requires Improvement overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced Sir John Kirk Close on 9 May 2018 as part of our inspection programme.

At this inspection we found:

A number of concerns regarding the provision of safe services and that governance systems were unclear in some places.

For example:

• The practice had not sufficiently mitigated risks associated with infection control, legionella or fire. The practice’s practice triage appointment system that reception worked to posed potential risks to patients which had not been adequately considered or addressed. There was a lack of clarity among staff about what amounted to a significant event and who assumed responsibility for patient safety alerts. Some aspects of medicines management and arrangements to ensure equipment was safe to use were not satisfactory. We were provided evidence after our inspection that the practice had taken action to address most of these issues.
• Not all staff had received a DBS check and not all clinical staff had been vaccinated against common communicable diseases. We were provided with evidence on inspection that DBS checks had been requested for staff who did not currently have these on file.
• Most patients found the appointment system easy to use and reported that they were able to access care when they needed it; though some said they occasionally had difficulty accessing routine appointments. The practice had changed their appointment system in response to patient feedback but the new system presented potential risks which had not been assessed or addressed.
• There was a focus on continuous learning and improvement though we were only provided with one two cycle audit from the last two years which demonstrated quality improvement.

However, we did see some areas of good practice. For example:

• We saw that the practice had systems in place to enable care and treatment to be delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• 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:

• Consider the way it engages with Patient Participation Group members to ensure that all members are able to participate in meetings.
• Consider ways to improve patient satisfaction with the nursing service provided by the practice.

We issued a warning notice to the provider after our inspection in respect of the concerns identified.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice