Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Southfield Way Surgery on 16 December 2015. Overall the practice is rated as good.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

Our key findings were as follows:

• Staff knew how to and understood the need to raise concerns and report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and acted upon.
• Risks to patients were assessed and well managed.
• Best practice guidance was used to assess patients’ needs and plan and deliver their care.
• 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 easy to understand but not readily available as patients had to ask for the practice leaflet.
• Patients said they found it easy to make an appointment with a GP of their choice and 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.
• There was a clear leadership structure and staff felt supported by management.

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

The provider should:

• Carry out periodic fire drills to ensure staff know how to follow the fire evacuation procedure.
• Carry out a Control of Substances Hazardous to Health (COSHH) risk assessment and ensure data regarding COSHH products used was readily available to staff.
• Formalise the multidisciplinary team meetings including recording and sharing the minutes of meetings.
• Introduce a system to record verbal/informal complaints.
• Ensure that the practice Care Quality Commission registration is updated to reflect the current partnership arrangement.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice