Letter from the Chief Inspector of General Practice

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

This inspection was an announced focused inspection carried out on 22 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 13 April 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.

At the announced February 2017 inspection we found;

• The practice had conducted comprehensive audits relating to medicine management performance and clinical care. All were aligned to guidance and showed improvements where appropriate.
• Quality improvement processes had been established and were jointly overseen by the practice manager and the clinical lead to maintain and build on improvements.
• The practice had continued to meet regularly with the patient participation group (PPG). The clinical lead had been in attendance at all three of their last meetings. The PPG told us there had been improvements in how the practice engaged with them.
• We found appropriate systems were in place to ensure legal authorities were obtained to administer vaccinations safely.
• Staff had received training in how to correctly code patient health conditions. The practice manager in partnership with the clinical lead undertook regular governance checks to alert them of any issues. We found the practices prescribing practices were consistent with the patients clinical coding.
• All staff were aware of the practice safeguarding lead and in their absence concerns were reported to the deputy safeguarding lead.
• We reviewed practice team meeting minutes and saw learning from complaints and safety incidents were shared and revisited to embed the changes into practice.
• Clinicians were apprised of changes to guidance at their monthly meetings. We saw alerts had been placed on the patient record system advising them of changes. We checked the patient record system and saw clinical adherence to national guidelines.
• The practice had introduced a policy for communicating with out of hour’s services. We found appropriate patients had been identified, clinical records had been appropriately updated and care plans were in place.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Shotgate Surgery on 13 April 2016. Overall the practice is rated as requires improvement.

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 and well managed, through infection prevention control audits, health and safety assessments.
• Clinical staff were responsible for their own professional learning.
• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• The practice had higher than local and national averages for screening patients for breast, cervical and bowel cancer.
• Patients said they were treated with compassion, dignity and respect.
• Information about services and how to complain was available and easy to understand.
• Some patients said that they experienced difficulties making an appointment with a named GP.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a leadership structure and staff felt supported by the practice management.
• The practice sought feedback from staff and patients, but did not consistently respond in a timely manner.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

• Review learning from complaints and safety incidents to ensure learning has been embedded in the practice.
• Implement a system to ensure all clinical staff are aware of and adhering to national guidelines.
• Ensure all staff are aware of the practice safeguarding lead.
• Implement a system to ensure that the practice communicates effectively with the out of hour’s services.

The areas where the provider must make improvement are:

• Conduct two cycle audits.
• Where audits or quality improvement processes identify areas for improvement ensure that they are acted upon and changes embedded.
• The practice must improve their engagement with their Patient Participation Group to actively seek and act on feedback.
• Ensure appropriate legal authorities are obtained to administer vaccinations safely.
• Ensure the health conditions of patients are coded correctly on their patient records.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice