Letter from the Chief Inspector of General Practice

We carried out an unannounced comprehensive inspection of this practice on 11 February 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Tudor Lodge Surgery on our website at www.cqc.org.uk.

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 Tudor Lodge Surgery on 11 February 2015. Overall the practice is rated as requires improvement.

Specifically we found it good for effective, caring and responsive services. It was also good for providing services for older people, people with long-term conditions, mothers, babies, children and young people, working-age population and those recently retired, people in vulnerable circumstances who may have poor access to primary care and people experiencing poor mental health. It required improvement for providing safe services and for being well led.

Our key findings were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• Risks to patients were assessed and well managed, with the exception of those relating to staff recruitment checks and aspects of building safety.
• 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 the practice had much improved the ability 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.

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

Importantly, the provider must:

• Ensure that the risks to patients, staff and visitors such as fire safety, infection control are risk assessed and actions put in place to mitigate those risks.
• Ensure that criminal records checks through the Disclosure and Barring Service (DBS) on these staff or any of the others that have joined the practice since January 2013 including the practice manager are undertaken

In addition the provider should:

• Ensure there are planned and recorded processes for regular meetings and decision making at the practice for significant events, safeguarding, and discussions about patient care.
• Ensure there is a system of monitoring that patient safety alerts were read and actioned, where appropriate, by staff.
• Ensure that records relating to staff training are maintained and up to date.
• Ensure that Patient Group Directions (PGDs) the written instructions for the supply or administration of medicines such as vaccines are signed for by the GP responsible before implementation.
• Ensure there is a system of tracking blank prescription printer paper through the practice when distributed to printers in consulting and treatment rooms.
• Ensure there are records kept of audits, checks and the monitoring of the quality of the service such as those for infection control, health and safety and cleaning.
• Ensure there is a system of management, testing and investigation of legionella (a bacterium that can grow in contaminated water and can be potentially fatal).
• Ensure that staff annual appraisals occurred.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

At our last visit in August 2013, we found although patients felt able to give feedback about the service they received, systems at the surgery were not fully effective in order to monitor the quality of the service provided. During this visit we found significant improvements had been made by the new practice manager and staff team.

We spoke with six patients who were visiting the surgery. All of the patients we spoke with were complimentary about and satisfied with the care and treatment they received. People told us they had been involved in the decisions made about their treatment. Comments included, "I have never once considered changing GP, I am satisfied with the service I receive”.

Patients told us staff showed them respect. One patient said "I have always found all of the staff to be polite and professional. I have always been spoken to in a considerate way”.

We spoke with staff who were knowledgeable about safeguarding vulnerable adults and protecting children and staff confirmed they had received training on this.

Staff were supported to maintain their clinical skills, however annual appraisals of some staff had not been undertaken.

Patients felt able to give feedback about the service they received, however, systems at the surgery were not fully effective in order to monitor the quality of the service provided.

We reviewed the information available to us about Tudor Lodge Surgery on 10 May 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.