Letter from the Chief Inspector of General Practice

We carried out a follow up inspection of Testvale Surgery on 4 August 2016 to check that action had been taken since our previous inspection in January 2016.

In January 2016 the practice was rated as overall good.The practice was good for effective, caring, responsive and well led services.

However we found that the practice required improvement in the safe domain due to breaches of regulations relating to safe delivery of services.

We found that the practice had not ensured that they had assessed monitored, managed and mitigated risks to the health and safety of service users. This was in relation to health and safety risk assessments, maintenance and checking of a defibrillator, Legionella assessments, equipment calibration and premises electrical testing.

We inspected the practice on 4 August 2016 to check that they had followed the action plan they had submitted and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection for Testvale Surgery on our website at www.cqc.org.uk

Our key findings for this review were as follows:

The provider had made improvements:

• The practice reviewed its water safety risk assessment in relation to Legionella to ensure that the water supply did not pose a risk to patients, visitors or staff.
• The practice had undertaken health and safety risks assessments and were working through action plans relating to improvements in that area.
• The practice had completed calibration of equipment and premises electrical testing.
• The maintenance and checking of a defibrillator had been updated and appropriate checks were completed.

The practice is now rated good for safe services.

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 Testvale Surgery on 28 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.
• 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 and easy to understand.
• 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.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the Duty of Candour.

We saw one area of outstanding practice:

The practice has a patient information and resource centre staffed by volunteers form their patient group Mondays to Fridays, for four hours per day.

The areas where the provider must make improvement are:

The provider must assess, monitor, manage and mitigate risks to the health and safety of service users. This is in relation to health and safety risk assessments, maintenance and checking of a defibrillator, Legionella assessments, equipment calibration and premises electrical testing.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

At the time of our inspection the provider did not have a registered manager in post. In this report the name of Dr Ian David Entwisle appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

Patients' diversity, values and human rights were respected. During our inspection we saw the consultations with the GP and Practice Nurse took place in single rooms which afforded privacy and confidentiality. We saw the surgery reception area was organised and managed effectively during busy times of the day.

Most patients told us they were very happy with the care they received. One patient told us: “I always feel happy with my care. I get good advice and options” Another person said: “I just happened to mention something in passing and they took a look and recommended a course of treatment which cured the problem” We received some negative comments regarding waiting times in the surgery when we spoke to one patient and these were passed on to the practice manager to investigate.

Appropriate arrangements were in place in relation to the recording of medicine. Details of the medication given were recorded in people's electronic records, including the batch number of any immunisations.

All clinical staff were required to provide evidence of their professional qualifications and registration. We saw that the GPs were on the Performer's List, which aims to provide further reassurance to members of the public that GPs practicing in the NHS are suitably qualified, have kept up to date with their training and have had the relevant checks. All nursing staff were registered with the Nursing and Midwifery Council (NMC) and copies of up to date registrations were held in their personnel files.

The provider took account of complaints and comments to improve the service. We looked at some of the complaints that had been received. We saw that the complaints had been investigated and responded to in an appropriate way. Any issues received were discussed and reviewed by the GPs and staff.