This practice is rated as Good overall. (Previous rating February 2017 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Southey Green Medical Centre on 19 February 2019 as part of our inspection programme.

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.
• 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.
• Staff  treated patients with compassion, kindness, dignity and respect.
• The practice organised and delivered services to meet patients’ needs. However, some patients commented they had difficulty accessing the practice by telephone to make an appointment and sometimes had to wait a long time to be seen once they attended for an appointment.
• There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Develop an overview of safety alerts and actions taken to share with relevant staff.
• Review systems for checking the immunisation status of staff in line with the Department of Health Immunisation Against Infectious Disease guidance (the Green Book).
• Take action to ensure the practice manager receives an annual appraisal.
• Improve the process for recording actions taken by a GP from hospital letters with regard to children who do not attend for a hospital appointment.
• Review the code used to identify vulnerable adults on the computer system.

• Continue to monitor the prescribing of hypnotic medication to ensure it is appropriate.
• Continue to listen to patient feedback regarding access to an appointment and length of wait to be seen when attending for an appointment.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 22 January 2016. The practice was rated as requires improvement for ‘well led’. After the comprehensive inspection, the practice wrote to us to say what they would do to improve their service.

We carried out an announced focused inspection on 1 February 2017 to check that the practice had followed their action plan. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Southey Green Medical Practice on our website at www.cqc.org.uk.

Overall the practice is rated as good. Specifically, following the focused inspection we found the practice to be good for providing well led services.

The following improvements had been implemented:

• We saw evidence that incident reporting and process was in place and there was shared learning across the practice team.
• We saw evidence that regular meetings were in

  took place with the practice manager and GP partners.

• Outdoor clinical waste bins had locking mechanisms in place.
• Cleaning fluids were stored safely in a locked storage room.
• We saw evidence that all staff (including practice nurses) had accessed on line safeguarding training.
• We saw evidence that all staff who undertook chaperoning duties (including the apprentice receptionist) had accessed chaperone training.
• We saw that a Disability Assessment had been completed for the building.

• We saw staff files that contained personal development plans and appraisals had been completed.

• The practice had developed a number of new policies and procedures.

• The practice did not have an active PPG however efforts were seen to recruit one

  being made to establish one and obtain patient views of the service.

• We saw the practice business continuity plan which had been updated, reviewed and monitored.
• Staff told us they knew who to approach if they had areas of concern.

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 Southey Green Medical Centre on 22 January 2016. Overall the practice is rated as good.

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.
• 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 although some patients reported that they did not know how to make a complaint.
• 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.
• The provider was aware of and complied with the requirements of the Duty of Candour.
• The practice had sought feedback from patients but did not have an active patient participation group.

The areas where the provider should make improvements are:

• Incident reporting and process is in place although shared learning could be improved across the practice.
• Regular meetings should be in place with the practice manager and GP's.
• Clinical waste bins were accessible as there was no locking mechanism.  This issue had been raised from the infection prevention and control audit.
• There was access to cleaning fluids which were situated on the second floor inside the premises. This issue had been raised from the infection prevention and control audit.

• Two practice nurses had level one safeguarding training from previous employment and should access current on line training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice