Letter from the Chief Inspector of General Practice

On 18 May 2016 we carried out an announced comprehensive inspection at Whitburn Surgery. The overall rating for the practice was requires improvement, having being judged as requires improvement for Effective and Well Led and inadequate for Safe The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Whitburn Surgery on our website at www.cqc.org.uk.

Following the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

• Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe care and treatment.

• Regulation 15 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Premises and equipment.

• Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance.

• Regulation 18 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Staffing.

This announced comprehensive inspection was carried out on the 5 January 2017 in order to review the action by the practice to be compliant with the regulations. Overall the practice is now rated as good.

• Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses; improvements had been made to the significant event reporting process.

• Risks to patients were assessed and well managed.

• Outcomes for patients who use services were good.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance.

• Staff were consistent and proactive in supporting patients to live healthier lives through a targeted approach to health promotion. Information was provided to patients to help them understand the care and treatment available.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• The practice had a system in place for handling complaints and concerns and responded quickly to any complaints.

• Patients we spoke with raised no concerns regarding making an appointment.

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• There was a leadership structure in place and staff felt supported by management. The practice sought feedback from staff and patients, which they acted on.

• The practice was aware of and complied with the requirements of the Duty of Candour regulation.

The areas where the provider should make improvements are:

• Develop an effective system for clinical audit.

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 Whitburn Surgery on 18 May 2016. Overall the practice is rated as requires improvement.

• Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses. Significant events were recorded at the practice; however there was no facility to ensure actions were completed or to document the lessons learned. There was not a comprehensive system in place to manage patient safety alerts.
• Risks to patients were not always assessed or well managed. For example, it was not known what actions had been addressed from a legionella risk assessment from some years ago and there were no regular fire drills.
• There was a recruitment policy in place and appropriate recruitment checks had been carried out.
• Security within the building was poor. Some cabinets containing patient records and some consulting rooms did not lock.
• Patients’ needs were assessed and care was planned and delivered, and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) best practice guidelines were followed.
• Data showed patient outcomes had been below average for the locality. For example the overall Quality and Outcomes Framework (QOF) score for 2014/15 showed the practice had achieved 88.2% of the total number of points available to them compared to the national average of 94.8%. However improvements had been made for the 2015/16 year and the overall score was 96.8%. The 2015/16 data had not been verified or published at the time of the inspection.
• Staff told us they had received some training; however we could not verify this as there were no training records to support this.
• Staff were consistent and proactive in supporting patients to live healthier lives through a targeted approach to health promotion. Information was provided to patients to help them understand the care and treatment available
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice had a system in place for handling complaints and concerns; however, there was no leaflet available to give patients information on how to complain.
• The practice provided good access to appointments for patients. Patients told us they were able to get an appointment with a GP when they needed one, with urgent appointments available on the same day. However, there were no extended opening hours.
• The practices ethos complied with the requirements of the Duty of Candour. However, the practices’ record keeping process for significant events did not support the requirements of Duty of Candour.

The areas where the provider must make improvements are:

• Ensure the practice’s system for significant events is reviewed.
• Ensure there is an effective system in place to manage patient safety alerts.
• Ensure the premises and equipment, including records, are held securely.
• Ensure they follow systems and processes in relation to health and safety and fire safety and understand the requirements and actions from the legionella risk assessment.
• Ensure staff receive appropriate support including appraisal and training relevant to their role.

The areas where the provider should make improvements are:

• Consider reviewing safeguarding information which is available for staff.
• Consider ways of more proactively identifying and supporting carers.
• Consider formal arrangements to be put in place for patients to see a female GP if necessary.
• Review the information available for patients who wish to make a complaint.
• Continue to progress with the setting up of a patient participation group and consider feedback from patients to improve services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice