Archived: Glebe Park Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Glebe Park Surgery on 21 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 kindness, dignity and respect and they were involved in decisions about their care and 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 the requirements of the Duty of Candour.
• The provider was not registered for the activity of maternity and midwifery with the Care Quality Commission.
• The practice did not have a patient participation group in place.
• A legionella assessment had not taken place at the practice however this was booked to be completed the week after the inspection.
• Not all staff had completed formal MCA training however staff were able to demonstrate an understanding of the act and could relate it to their roles.
• Staff files did not contain references for staff employed as stated in the recruitment policy.

The areas where the provider should make improvement are:

• Ensure a patient participation group (PPG) is in operation.
• Ensure registration is updated to include the maternity and midwifery activity.
• Ensure any actions identified from the legionella assessment are acted upon and the infection control policy is updated to include this.
• Ensure that staff files are kept in line with Schedule 3 of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and that the practice recruitment policy is adhered to.
• Access MCA (mental capacity training) for all staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice