Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 12 January 2016 where breaches of legal requirements were found. After the inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12 Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this desk-based focussed inspection on 31 August 2016 to check that the practice had followed their plan to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Steven Shackman Practice on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services.

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 8.30am on 12 January 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 a system in place for reporting and recording significant events. However there were inconsistencies in the recording of significant events, and analyses were not always thorough.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had 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.
• Patients said they did not have to wait too long for an appointment although an appointment with a named GP could take up to three weeks. Urgent appointments were available the same day.
• The practice had adequate facilities and was 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 was a vision to deliver high quality care and promote good outcomes for patients.
• There was a programme of clinical audit in place to monitor and improve outcomes for patients.

We saw one area of outstanding practice:

The practice operated a ‘Health Information Station’ run by a team of patient volunteers. The volunteers help patients to find information on health related issues from books, leaflets, DVDs/CDs and the internet. The books, DVDs and CDs were available to patients on free loan. The volunteers also helped patients access local support groups such as those for weight loss, social services and local fitness classes as well as signposting patients to community events.

However there were areas of practice where the provider must make improvements:

• Review the procedures for managing significant events and national patient safety alerts.
• Review safeguarding policies and procedures.
• Ensure actions are completed from infection control audits and maintain records of the cleaning of the privacy curtains in the consultation rooms.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During our inspection we spoke with seven people using the service, the practice manager, a GP who was the senior partner, a nurse practitioner, a practice nurse, a health care assistant and two reception staff. The majority of people we spoke with were satisfied with the service provided. However, three people told us that sometimes they had to wait a long time to get a routine appointment and the doctors were usually running late on the day of their appointment. Comments included, “I sometimes have to wait up to two weeks for a routine appointment” and “Once I had to wait more than one hour in the waiting room to see the doctor.”

People told us that although sometimes they waited longer than they expected to see the doctor their consultations were never rushed even though the doctors were running late. People said the doctors always listened to them and they were involved in their treatment. One person said, “the doctors explain my medical conditions and the treatment options in detail.”

Procedures were in place to manage cross infection risks and ensure the risks were minimised. The practice was clean, hygienic and well equipped and staff had been adequately trained in infection control procedures.

Staff had received appropriate support and training to ensure they were able to meet the needs of people using the service. This included mandatory training, training specific to the job role, a comprehensive induction programme when they started working at the service and annual appraisals to monitor performance.

Systems were in place to monitor the standards of care and treatment provided including annual patient satisfaction surveys and a range of clinical audits. Where shortfalls were identified, improvements to the service had been made. Risk assessments had also been carried out to ensure the environment was safe for people using the service.