- GP practice
High Road Surgery
Important:
The provider of this service changed - see old profile
All Inspections
1 August 2017
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at the High Road Surgery on 20 October 2016. The overall rating for the practice was requires improvement. The full comprehensive report published in March 2017 can be found by selecting the ‘all reports’ link for High Road Surgery on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 1 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 20 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is now rated as good.
Our key findings were as follows:
- There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
- The practice had a comprehensive compliment of policies and procedures that were practice specific and version controlled.
- Outcomes from the Quality and Outcomes Framework was in line with local and national averages.
- The practice had clearly defined and embedded systems to minimise risks to patient safety, including the purchase of a defibrillator, a fire risk assessment and regular alarm testing and fire drill as well as an infection control audit and a legionella assessment.
- All staff members had completed training relevant to their role including safeguarding and information governance.
- The practice had identified 35 patients as carers (1% of registered patients).
- The practice had established a patient participation group.
- There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients.
- The practice had a hearing loop installed in the patient waiting area.
However, there were also areas of practice where the provider could make improvements.
In addition the provider should:
- Continue to work to improve the uptake of patient screening in cervical cytology and breast and bowel screening.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
20 October 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at High Road Surgery on 20 October 2016. 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. However, not all significant events were recorded and recorded events were predominantly events that took place outside the practice. The practice did not have a significant events policy.
- Risks to patients were assessed and well managed, with the exception of those relating to staff training and the lack of risk assessment carried out for not having a defibrillator.
- Information about services and how to complain was available and easy to understand.
- The practice had a complaints policy however; they told us that they had not received any complaints in the past 12 months and we saw no complaints had been recorded since 2013.
- The practice had a portable ramp for disabled access and translation services. However, there were no accessible facilities for people with a disability and no hearing loop for people with a hearing loss .
- Data showed patient outcomes were comparable to the national average.
- Clinical audits had been carried out and we saw evidence that audits were driving improvements to patient outcomes.
- 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 number of policies and procedures to govern activity, but some were overdue a review and were not practice specific.
- The provider was aware of and complied with the requirements of the duty of candour
- The practice had not established a patient participation group to seek feedback and improve services.
- The practice had identified relatively few carers who might need extra support.
- The practice did not have a mission statement, however staff knew and understood the practices values and informed us this was revisited at the practice meetings. however, the practice did not have a formal strategy or supporting business plan to reflect the vision and values.
The areas where the provider must make improvements are:
- Ensure a risk assessment is carried out for not having a defibrillator in the practice during an emergency.
- Ensure all staff receive and complete required training to carry out their roles effectively, including safeguarding, infection control, fire safety, information governance and basic life support.
- Ensure systems are in place to actively seek feedback from people to access and monitor the quality of service being provided. Ensure these are analysed and action is taken to make improvements including the review of all complaints and feedback from Patient Participation Group (PPG).
- Review and update policies so that they are practice specific.
In addition the provider should:
- Ensure systems for recording and reporting significant events is reviewed including a significant events policy.
- Review systems to identify carers in the practice to ensure they receive appropriate care and support. Consider ways to support patients who are hard of hearing.
- Ensure that the practice strategy and supporting business plans are documented to reflect the practice vision and values.
- Consider carrying out regular fire drills.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice