Birchwood Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 4 March 2016. Improvements were required in relation to safe care and treatment. The practice sent in an action plan informing us about what they would do in relation to the following;

• The practice had not ensured that patient specific directives were in place for healthcare assistants to be able to administer certain types of vaccinations.

During the initial inspection we also found other areas where improvements were required:

• Ensure patients in the waiting rooms and throughout the premises are monitored, in case they become suddenly unwell.
• Review the arrangements for the segregation of clean and dirty areas for hand washing and waste disposal direct to sewage. The practice were limited in changing this as it would involve costly building work and had noted the shortcoming in their business plans and risk assessments.
• Ensure cold chain temperature recording is complete with actions and comments when temperatures exceed the recommended range.
• The practice had decided to treat patients alongside one another in a treatment room. There should be clear signage to inform patients that they can request improved privacy if they wish as conversations could be overheard. The practice should actively solicit patients’ views on the shared treatment area and act on them as necessary.
• Ensure all staff receive timely and adequate appraisals.

They told us the majority of these issues were addressed and provided us with statements and/or evidence to show they had taken the action to address the concerns.

We undertook a desk top review on 3 November 2016 to make a judgement about whether their actions had addressed the requirements.

The overall rating for the practice is good. You can read our previous report by selecting the ‘all reports' link on our website at www.cqc.org.uk

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 Birchwood Surgery on 4 March 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.
• 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.
• 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.
• 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 area where the provider must make an improvement is:

• Patient Specific Directives must be in place for healthcare assistants to be able to provide certain types of vaccinations.

The areas where the provider should make improvements are:

• Ensure patients in the waiting rooms and throughout the premises are monitored, in case they become suddenly unwell.
• Review the arrangements for the segregation of clean and dirty areas for hand washing and waste disposal direct to sewage. The practice were limited in changing this as it would involve costly building work and had noted the shortcoming in their business plans and risk assessments.
• Ensure cold chain temperature recording is complete with actions and comments when temperatures exceed the recommended range.
• The practice had decided to treat patients alongside one another in a treatment room. There should be clear signage to inform patients that they can request improved privacy if they wish as conversations could be overheard. The practice should actively solicit patients’ views on the shared treatment area and act on them as necessary.
• Ensure all staff receive timely and adequate appraisals.

We saw several areas of outstanding practice:

• All GP appointments were 15 minutes in length. This had been in place for approximately three to four years and the practice informed us they had noted a drop in waiting times as a result.
• The practice sent out questionnaires to patients with certain long term conditions in preparation for their review attendance. These pre appointment questionnaires assisted clinical staff in preparing for the reviews and allowed more time during consultation to focus on the patient.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice