South Green Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at South Green Surgery on 14 June 2017. The overall rating for the practice was good, with requires improvement for well-led. The full comprehensive report on the June 2017 inspection can be found by selecting the ‘all reports’ link for South Green Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 28 December 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 14 June 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as good.

Our key findings were as follows:

• The organisation of formal governance arrangements including the systems for assessing and monitoring risks was greatly improved.
• Although the practice had identified more patients who were carers, this could be improved further. Only 0.7% of the patient population had been identified as being a carer.
• The practice had implemented a system to monitor the use of blank prescription forms and pads.
• The practice had improved the security of the storage of external clinical waste.
• The practice had put in place an action plan following their patient survey and posted this on their website.

However, there was one area of practice where the provider still needs to make improvements.

The provider should:

• Continue to improve the identification of carers on their register.

At our previous inspection on 14 June 2017, we rated the practice as requires improvement for providing well led services as some of the governance systems required strengthening and reorganising. At this inspection we found that this was much improved therefore they are now rated as good for well-led.

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 South Green Surgery on 14 June 2017. 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 a system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed, however organisation and completion of some risk assessments required strengthening.
• Risks associated with the storage of clinical waste awaiting collection were not sufficiently mitigated.
• There was no system in place to monitor the use of blank prescription forms and pads.
• Data from for 2015 to 2016 showed some patient outcomes were low compared to the national average, however unpublished data for 2016 to 2017 showed that improvements had been achieved. All other patient outcomes were in line with or above CCG and national averages.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Information about services and how to complain was available. Complaints were fully investigated.
• Results from the national GP patient survey published in July 2016 showed patients were treated with compassion, dignity and respect.
• Patients’ rated the practice above CCG and national average for all but two aspects of care. These were around their level of involvement in decision making and how well treatment was explained to them, when seen by a GP. Patient satisfaction scores for these two areas were lower than average.
• Comments cards showed that patients were satisfied with the level of service provided although two commented that access to appointments had deteriorated. Patient survey data showed patients rated the practice above clinical commissioning group (CCG) and national average for their access to appointments.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had completed a sensory audit to determine what adjustments were needed to improve access to patients. Changes the practice had made included painting the doorframes contrasting colours to be easily visible to those with sight loss or impairment.
• The practice had identified 19 patients as carers (0.6% of the practice list).
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvement are:

• Improve the organisation of formal governance arrangements including systems for assessing and monitoring risks.
• Improve the identification of patients who are carers.
• Implement a system to monitor the use of blank prescription forms and pads.
• Improve the security of the storage of clinical waste.
• Continue monitoring patient survey data and take action to improve patient satisfaction where required.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice