Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Grove Road Practice on 13 October 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for The Grove Road Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 11 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations 9(1) Person-centred care, 12(1) and 12(2) Safe care and treatment, and 18(2) Staffing of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014 that we identified in our previous inspection on 13 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• Risks to patients were assessed and well managed.
• All staff had received training relevant to their role.
• The practice sent response letters for all patients who had made a complaint with all the relevant information.
• The practice undertook regular governance meetings for non-clinical staff.

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

The provider should:

• Review practice procedures to ensure that the outcomes for patients with long term conditions are improved especially for patients with diabetes.

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 Grove Road Practice on 13 October 2016. Overall the practice is rated as requires improvement.

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

• Some risks to patients were assessed and managed; however the practice had not undertaken a recent fire and legionella risk assessment and a health and safety risk assessment of the premises. There was no system to record the cleaning carried out on a daily basis; records were not maintained of checks made for oxygen and defibrillator. There was no formal system to monitor implementation of medicines and safety alerts.
• 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; however the outcomes for patients with long-term conditions were lower than local and national averages. Many staff had not undertaken mandatory training including safeguarding vulnerable adults, infection control, fire safety, mental capacity act and information governance
• 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.

There were areas of practice where the provider must make improvements:

• Ensure that all staff have basic life support, safeguarding vulnerable adults, infection control, fire, mental capacity act and information governance training relevant to their role.
• Ensure that an up to date fire, legionella and health and safety risk assessment is undertaken and all the recommendations from the risk assessment are actioned.
• Ensure records are maintained of oxygen and defibrillator checks.
• Ensure that the outcomes for patients with long term conditions are improved.

There were areas of practice where the provider should make improvements:

• Review practice procedures to ensure there is a system in place to monitor implementation of medicines and safety alerts.
• Review practice procedures to ensure daily cleaning logs are maintained.
• Review practice procedures to ensure identification of patients with Chronic Obstructive Pulmonary Disease (COPD) is improved.
• Review practice procedures to ensure response letters are sent to all patients who had made a complaint.
• Consider formal meetings for non-clinical staff.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice