Letter from the Chief Inspector of General Practice

On 3 November 2015 we carried out a full comprehensive inspection at Willowbank Surgery. The inspection was rated as requires improvements and improvements were specifically required in the following areas:

• Regulation 12 of the Health and Social Care Act (Regulated Activity) Regulations 2014, Safe care and treatment.
• Regulation 15 of the Health and Social Care Act (Regulated Activity) Regulations 2014, Premises and Equipment.
• Regulation 17 of the Health and Social Care Act (Regulated Activity) Regulations 2014, Good governance

We carried out an announced comprehensive inspection at Willowbank Surgery on 22 November 2016. We inspected each domain.

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.
• The practice had a risk assessment profile in place to ensure risks and hazards were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with 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 found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• 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.

The areas where the provider should make improvements are:

• Add the full address of the Parliamentary and Health Service Ombudsman(PHSO) in the complaints policy.
• Have a formal written succession plan in place.
• Review and increase the carers numbers in the practice.

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 Willowbank Surgery on 3 November 2015. Overall the practice is rated as requires improvement.

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.

• The practice had a number of policies and procedures to govern activity; however we identified areas where policies were not in place for example infection control.
• 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 areas where the provider must make improvements are:

• Ensure infection control process and procedures are fully implemented.

• Ensure a safe practice environment is maintained with regards to Health and Safety of patients for example risk assessments to be in place, replacing both treatment beds, replacing all treatment rooms’ curtains and replace laminate flooring in the waiting area.

• Ensure oxygen is available on the premises to deal with emergency major incidents.

• Ensure the practice policies are a true reflection of practice working process.

In addition the provider should:

• Review staffing levels and have a plan in place for emergencies.

• Review the benefits of a practice defibrillator. External guidance and national standards encourages practices to have defibrillator, for further guidance please see CQC Dr Nigel Sparrow guidance - Myth Busters one.

• Provide practice information in appropriate languages and formats.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice