All inspections: The Fryent Way Surgery

This practice is rated as requires improvement overall. (Previous rating 7 January 2016 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at The Fryent Way Surgery on 28 June 2018 as part of our inspection programme.

At this inspection we found:

The practice had ineffective systems to manage risk. This included induction, emergency medicines, equipment, fire safety, infection control and significant events.
Systems to keep people safe and safeguarded from abuse were in place.
Staff recruitment practices were not in line with legal requirements.
Systems had not been implemented effectively to ensure that all health and safety risk assessments such as Legionella risk assessments were completed.
Care and treatment was delivered according to evidence-based guidelines.
Patients did not always find the appointment system easy to use and reported that they were not always able to access care when they needed it.
The practice was actively addressing recent challenges and making positive changes.
The practice achievement for childhood immunisations were above the 90% target and highlighted as positive outliers.
Staff involved and treated patients with compassion, kindness, dignity and respect.

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 for patients.
Establish effective systems to and processes to ensure good governance in accordance with the fundamental standards of care.
Ensure staff employed receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.
Ensure recruitment procedures are established and operated effectively.

The areas where the provider should make improvements are:

Take action to highlight appointment and attendance details on the two-week referral log.
Take action to ensure that all staff have read the newly updated safeguarding policies.
Review and amend policies to ensure they contain up to date staff details.
Consider incorporating the discussion of evidence based guidelines into educational meetings.
Review and improve on clinical indicators where performance is not as expected.
Introduce regular audits and share findings with all staff.
Improve the sharing of information with all staff.
Review and improve patient satisfaction with interactions with staff.
Implement the Accessible Information Standard protocol.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Fryent Way Surgery on 7 January 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 an effective system in place for reporting and recording significant events.
Risks to patients were assessed and well managed.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had 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 about services and how to complain was available and easy to understand.
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 practice proactively sought feedback from staff and patients, which it acted on.
The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider should make improvements are:

Ensure the complaints policy is reviewed and implement version control mechanisms to ensure out of date versions are removed from circulation.

Ensure the business continuity plan includes the contact details for a named person at the alternative location and review the arrangements for holding copiesof the plan.

The practice should consider steps to improve patient privacy at the reception desk.

Chief Inspector of General Practice

Archived: The Fryent Way Surgery