Radbrook Green Surgery

This inspection was a desk-based review carried out on 26 February 2019.

We previously carried out an announced comprehensive inspection at Radbrook Green Surgery on 20 November 2018. Overall the practice was rated as good with requires improvement for providing safe services. No breaches in regulations were identified, however we made some good practice recommendations. The full comprehensive report on the November 2018 inspection can be found by selecting the ‘all reports’ link for Radbrook Green on our website at .

We carried out this desk-based review on 26 February 2019 to confirm that the practice had obtained the required staff checks and actioned the recommendations made. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

Overall the practice remains rated as good and Safe is now rated good.

We found that:

• The provider had reviewed and strengthened their recruitment procedures. All but one of the outstanding recruitment checks had been obtained for the staff we previously reviewed. The provider was in the process of obtaining all of the required checks for a new member of staff, who was due to commence working at the practice shortly.
• Significant improvements had been made in relation to staff training. The provider had developed an action plan and were reviewing staff completion rates on a monthly basis. Training records showed the majority of staff had since completed essential training, to include safeguarding.
• The practice had reviewed and improved telephone access to the practice. No verbal or written complaints had been received from patients since improvements to the telephone system had been implemented on 24 January 2018. A telephone survey had been developed and distributed to capture patient feedback, however no responses had been received to date. The practice planned to run a telephone survey for two weeks every quarter to gain patient feedback.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Radbrook Green Surgery on 6 November 2014. The overall rating for the practice was outstanding. The practice was rated as outstanding for providing caring and responsive services and rated good for providing safe, effective and well-led services. The full comprehensive report on the November 2014 inspection can be found by selecting the ‘all reports’ link for Radbrook Green Surgery on our website at .

This inspection was an announced comprehensive inspection carried out on 20 November 2018.

This practice is rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Outstanding

Are services responsive? – Good

Are services well-led? - Good

At this inspection we found:

• The practice had clear 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.
• There were systems in place for identifying, assessing and mitigating risks to the health and safety of patients and staff.
• The practice had systems, processes and practices in place to protect people from potential abuse. Staff were aware of how to raise a safeguarding concern and most staff had received safeguarding training appropriate to their role. However, not all of the required staff recruitment checks had been obtained prior to employment.
• 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 felt genuinely cared for and spoke very highly of the care and treatment they received.
• The practice had good facilities and was equipped to treat patients and meet their needs.
• Some patients reported difficulties contacting the practice by telephone. The practice acknowledged the difficulties and were taking action to improve their systems and patient experiences.
• The practice worked closely with outside agencies such as nursing homes and charities in the local area to improve the care delivered.
• The practice actively worked with the patient participation group (PPG) to meet the needs of their patients. They told us that the practice leaders were very receptive, always listened to them and took any suggestions on board to improve the service for patients.
• Information to support patients with making a complaint was readily available.
• There was a focus on continuous learning and improvement at all levels of the organisation.

We saw an area of outstanding practice:

The practice provided several support groups and were involved in a number of social initiatives. These included a support group for carers of people with dementia, a bereavement group and a support group for people with chronic fatigue and Myalgic Encephalopathy (M.E). Patients had access to a community and care co-ordinator who assisted patients of any age in need of help, support and advice by offering a signposting service. This included advice regarding care, transport, benefits, financial support, local support groups, housing and social isolation. A befriending service was also available to those most vulnerable to loneliness and isolation and at risk of being admitted to hospital and losing their independence.

The areas where the provider should make improvements are:

• Ensure all staff complete outstanding essential training.
• Continue to review and improve telephone access to the practice.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.