Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Almondbury Surgery on 9 June 2016. The overall rating for the practice was good. However; we rated the practice as requires improvement for providing well led care. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for The Almondbury Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 31 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the issues that we had identified in our previous inspection on 9 June 2016. This report covers our findings in relation to those requirements.

The practice has now met the legal requirements in the key question of well led and is now rated as good for this area of activity.

Our key findings were as follows:

• The practice had completed an infection prevention and control audit, and taken steps to address issues identified.

• The practice had taken a number of steps to improve the process for making appointments. A patient information leaflet had been produced to provide feedback to patients regarding the changes.

• The partners at the practice had worked with staff to produce a business plan. This provided an outline of the goals for the next three to five years.

• We reviewed three completed clinical audits and saw that these had been discussed at clinical meetings and that learning from these was being shared.

• We saw that care plans were in use for patients with long term conditions, which included guidance for patients during exacerbation of their condition.

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 The Almondbury Surgery on 9 June 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. However we saw that an infection prevention and control (IPC) audit had not been undertaken by the provider within the last two years.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with 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. Improvements were made to the quality of care as a result of complaints and concerns.
• Urgent appointments were available the same day for patients that needed them.
• 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 sought feedback from patients through the patient participation group and the Friends and Family test.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• Undertake an infection prevention and control audit and implement identified actions.

• Act on feedback provided by the GP national survey and the Friends and Family test to improve processes for making appointments.

• Develop a strategic and business plan for the practice.

• Ensure clinical audit cycles are completed, to monitor and evaluate improvements in patient outcomes.

  In addition the provider should:

• Review their approach to the use of care planning templates for patients with identified needs.

• Consider developing and providing a locum pack for use by temporary clinical staff.

• Consider including reference to the Parliamentary and Health Service Ombudsman in the written response to complaints.

• Consider seeking feedback from staff in relation to the strategic development of the practice.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice