20 January 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at 102 The Avenue Surgery on 20 January 2015. Overall the practice is rated as good.
Specifically, we found the practice to be requiring improvement for providing safe services, good for providing effective, caring, and well-led services and outstanding for providing responsive services. It was outstanding for providing services for people whose circumstances make them vulnerable and people experiencing poor mental health. It was good for providing services for older people; people with long term conditions; families, children and young people; working age people (including those recently retired and students) and people experiencing poor mental health.
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. Information about safety was recorded, monitored, appropriately reviewed and addressed in a timely manner.
- Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
- Information about services and how to complain was available and easy to understand.
- Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
- There was a clear leadership structure and staff felt supported by management.
- The practice proactively sought feedback from staff and patients, which it acted on.
We saw two areas of outstanding practice:
- The practice provided a specialised service for homeless people at a local hostel which included a drop-in clinic once a month at the hostel. This catered for residents registered with the practice who declined attendance at the practice or the local hospital. Service provision included treating severely mentally ill patients with complex mental, social and physical problems. The practice also operated an open surgery at the practice each morning between 10am-11am which particularly catered for homeless patients who did not have the resources to telephone the practice for an appointment.
- The practice had an in-house counselling service where patients could access weekly counselling sessions to treat bereavement, depression, anxiety, relationship issues, sexuality orientation and managing long term conditions such as Parkinson’s disease. The GPs worked closely with community psychiatrists to review mental health patients to facilitate better communication regarding patients overall care.
However there were areas of practice where the provider needs to make improvements.
Importantly the provider must:
- Ensure Disclosure and Barring service (DBS) checks are undertaken for all staff who undertake chaperone duties at the practice or undertake a risk assessment if the decision is made not to perform DBS checks.
The provider should:
- Ensure all staff who undertook chaperone activities were suitably trained.
- Ensure availability of an automated external defibrillator (AED) or undertake a risk assessment if a decision is made to not have an AED on-site.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice