Letter from the Chief Inspector of General Practice

On 19 May 2016 we carried out an announced comprehensive inspection at Glenfield Surgery. The practice was found to be requires improvement in safe, caring, responsive and well-led. It was found to be good in the effective key question.

The overall rating for the practice was requires improvement .The full comprehensive report on that inspection can be found by selecting the ‘all reports’ link for Dr JG Cooper and Partners on our website at www.cqc.org.uk.

As a result of that inspection we issued the practice with requirement notices. This was in respect of the governance of the practice as we found there were ineffective systems to monitor risk to patients. We also had concerns regarding the process for managing serious events.

This inspection was an announced comprehensive inspection on 13 July 2017. Overall the practice is now rated as ‘Good’.

Our key findings 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 been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• The practice was responsive to the needs of patients and tailored its services to meet those needs.
• Patients prescribed high risk medicines were well managed.
• 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.
• There was continuity of care, with easy access to GPs and nurses.
• 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 areas where the provider should make improvements are:

• The practice should continue to take positive steps identify carers on its patient list.

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 Dr JG Cooper & Partners on 19 May 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, we found that incidents had occurred that had not been investigated and reported as such as they were non clinical which had not been identified as a significant event.

• Risks to patients were not fully assessed and well managed. The practice did not have risk assessments such as a fire risk assessment and health and safety risk assessment.

• There had been no infection control audit completed however this was completed and forwarded the day after the inspection.

• Safety alerts were received and forwarded to staff in the practice to action as necessary.
• Portable appliance testing had not been carried out, however equipment had been calibrated and checked

• Not all staff that acted as a chaperone had completed chaperone training, received a DBS check or had a risk assessment undertaken to determine if this was needed.

• Data showed patient outcomes were comparable to the national average.

• Audits had been carried out that were driving improvements to patient outcomes.
• Patients said they were treated with compassion, dignity and respect.

• The practice had identified 22 patients as carers (0.13% of the practice list). The practice identified this as an issue and since the inspection had began to look at the processes to be able to increase this, such as amending the new patient registration form and posters promoting carers.

• Patients were able to get an appointment on the day and were happy with the appointment system and availability.

• Staff said they felt respected, valued and supported, particularly by the partners in the practice.

• The practice management team had recently seen changes with new staff recruited to roles and the definition of the different aspects of managing the practice were not always clear as to who was responsible and for what.

• The practice had a number of policies and procedures to govern activity, but some were overdue a review and were not all specific to the practice, for example some had incorrect telephone numbers listed

The areas where the provider must make improvements are:

• Introduce robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses including non-clinical.
• Ensure formal governance arrangements are introduced with systems for assessing and monitoring risks including fire safety, health and safety and portable equipment testing.
• Ensure chaperones have a DBS check in place or a policy or risk assessment in place to define the requirements for chaperones to have a DBS check.

In addition the provider should:

• Review and update procedures and guidance to make sure they are specific to the practice.
• Clarify the management structure and ensure roles and responsibilities are clearly defined.
• Ensure all staff who act as a chaperone are competent to fulfil the role
• Review process and methods for identification of carers and the system for recording this. To enable support and advice to be offered to those that require it.
• Ensure the prescription forms that were left in printers in rooms are kept secure.
• Identify issues in relation to exception reporting.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice