Baslow Road Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Baslow Road Surgery on 13 December 2016. The overall rating for the practice was good with requires improvement for being well-led. The full comprehensive report from December 2016 inspection can be found by selecting the ‘all reports’ link for Baslow Road Surgery on our website at www.cqc.org.uk.

This inspection was a desk based review carried out on 18 July 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 13 December 2016. This report covers our findings in relation to those requirements.

Overall the practice is rated as good.

Our key findings were as follows:

• The provider submitted to us further evidence as part of this inspection to support the governance framework and the delivery of good quality care.
• The arrangements for identifying, recording and managing risks, issues and implementing mitigating actions had been reviewed to include how actions taken or updates were recorded.
• The practice reviewed how it captured feedback from patients following our December 2016 inspection and implemented new methods to capture feedback.
• The provider reviewed the information available to patients to explain the complaints process and placed notices in each site.

In addition the provider should:

• Continue to review the opportunity for patient engagement, particularly provision of a patient participation group at the Baslow Road site.

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 Baslow Road Surgery on 13 December 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events. However, at the time of inspection the practice did not have a significant event policy.
• There was a clear leadership structure and staff felt supported by management.Some practice specific policies were available for staff to use. However some of those we looked at were incomplete or did not have a sign off date.The practice responded to the issues pointed out during the inspection and submitted updated evidence to us. These issues should have been dealt with more proactively and captured as part of regular reviews. 
• Some risks to patients were assessed, however not all actions taken to minimise risk were documented. For example, actions taken as part of the legionella risk assessment, flushing outlets and monitoring water temperatures, were not recorded.
• 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 how to complain was on the practice website and in the practice leaflet. Patients told us they had to complain to obtain a copy of the practice complaints process. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they sometimes had to wait for over two weeks to see a named GP. However same day appointments were available for those who required them. 
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. 
• The provider was aware of the requirements of the duty of candour. 

We saw one area of outstanding practice:

• Staff at the practice developed a mentorship programme for nurses joining the practice who were undertaking the practice nurse course at the university. Practice nurses told us they felt extremely supported to complete the course and obtain the additional skills and competence to care for patients in the GP surgery setting.

The areas where the provider must make improvement are: 

• Ensure practice specific policies and procedures are available to staff to support them in their role. All policies should be signed off, complete, reviewed and updated as necessary.
• Ensure appropriate risk assessments are in place and actions taken as a result are captured and documented in a timely manner.

The areas where the provider should make improvement are:

• Review information available to help patients understand the complaints system.
• Review the opportunity for patient engagement, particularly provision of a patient participation group at the Baslow Road site.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice