Updated 18 April 2017
Letter from the Chief Inspector of General Practice
The practice is rated good overall and good for providing safe services.
We carried out an announced comprehensive inspection of this practice on 17 November 2015. The overall rating for the practice was good. However, a breach of legal requirements was found during that inspection within the safe domain. After the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the legal requirements. We conducted a focused inspection on 17 March 2017 to check that the provider had followed their action plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.
During our previous inspection on 17 November 2015 we found the following area where the practice must improve:
Ensure that all GPs are trained to level three children’s safeguarding.
Ensure that a fire risk assessment, regular drills and fire training for staff are all carried out.
Our previous report also highlighted the following areas where the practice should improve:
Continue to improve the uptake of new patient and NHS health checks.
Continue to improve patient recall and reviews for patients with a learning disability and those living with long term conditions.
Build on the work to demonstrate quality improvement by increasing the number of full cycle audits conducted within the practice.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk
During the inspection on 17 March 2017 we found:
All clinical staff were now trained in children’s safeguarding level three.
The practice conducted regular fire drills, fire training and fire risk assessments in accordance with practice policy.
We also found the following in relation to the areas where the practice should improve:
The practice was taking steps to improve the uptake of new patient and NHS health checks within the practice. Patients were sent a letter inviting them to attend and reminders about their appointments by text.
The practice was taking steps to improve patient recall and reviews for patients with a learning disability and those living with long term conditions. The Quality and Outcomes Framework (QOF) performance results for the practice in 2015/2016 were 97% (92% clinical commissioning group and 95% nationally) which was an increase from 85% in 2014/2015. (QOF is a system intended to improve the quality of general practice and reward good practice). The practice now had a policy in place to phone non-attenders which had improved uptake.
The practice had increased the number of full cycle audits conducted within the practice and four full cycle audits had taken place over the last 12 months.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice