Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection 2 December 2015 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at The Koh Practice on 16 November 2017. This was as part of our inspection programme and also to follow up on outstanding issues from the previous inspection.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

• There was a strong focus on continuous learning and improvement at all levels of the organisation.

• Action had been taken in regard to outstanding issues from the previous inspection. This included the management of vaccines and improvement to governance of the practice.

• The practice had very good patient satisfaction survey results.

The areas where the provider should make improvements are:

• Introduce a patient participation group.

• Complete an annual infection and prevention control audit and provide additional training for the infection control lead.

• Maintain more detail records for incident reporting.

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 Koh practice on 2 December 2015. Overall the practice is rated as good.

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. Information about incidents was recorded, monitored, appropriately reviewed and addressed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

• 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 was equipped to treat patients and meet their needs.
• Staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

The area where the provider should make improvement is:

• Governance systems and process are be developed further to monitor and assess the whole service in relation to risk and improvement. This includes quality assurance of internal processes including checking of emergency medicines and the safe storage of vaccines.

• All staff who chaperone are to be trained and have an up to date Disclosure and Barring Service (DBS) checks.

• There should better recording of significant events that detail action taken and lessons learned.

• Staff should receive annual appraisal.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice