A J Cole and Partners Also known as Woodstock Bower Surgery

This practice is rated as Good overall. (Previous inspection June 2015 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at A J Cole and Partners on 20 March 2018 as part of our inspection programme.

At this inspection we found:

• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However, there was a lack of records to evidence all staff had received up-to-date safety training appropriate to their role.
• There were systems in place for safe management of medicines however, there were some shortfalls in the storage of vaccines.
• The practice was clean and tidy but there were some shortfalls in systems to prevent, and control the spread of infections.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it although some people said there was a wait to see a GP of their choice. The practice had continually reviewed and adjusted the appointment system.
• There was a focus on continuous learning and improvement at all levels of the organisation.

We observed one area of outstanding practice:

The practice was proactive in monitoring prescribing in the practice and had worked closely with the clinical commissioning group (CCG) pharmacist and employed a practice pharmacist to drive improvements in this area. Data provided showed year on year improvement across all the areas monitored by the CCG. The practice had also identified issues relating to over ordering of medicines by third parties and had been the first practice in Rotherham to take part in audits to assess related processes. Following improvements made as a result of the audits they had successfully reduced their prescribing budget by 10% and evidence of further reductions for the year to date were also seen. The process for improvement had been rolled out across Rotherham.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients (for details of the breach please see the requirement notice at the end of this report).

The areas where the provider should make improvements are:

• Review the practice protocol for the management of letters received into the practice and share this with staff responsible for related tasks.
• Consider developing a written policy and procedure and central action log to support the management of alerts.
• Develop a written duty of candour policy and procedure.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice