Letter from the Chief Inspector of General Practice
This practice is rated as Good overall.
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people living with dementia) - Good
We carried out an announced comprehensive inspection at Heeley Green Surgery on 23 January 2018 as a new provider had registered with CQC to provide regulated activities from this location in September 2017.
At this inspection we found:
- The practice had conducted safety risk assessments and there were action plans in place to address any risks identified.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence -based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect and patient feedback was positive about the care they received.
- Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
- Structures, processes and systems to support good governance and management were clearly set out, understood and effective.
- There was a clear leadership structure and staff told us they felt respected, supported and valued. They felt part of a team and were proud to work in the practice.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
The areas where the provider should make improvements are:
- Follow the significant event analysis (SEA) policy when reporting incidents.
- Review how the clinical meetings are recorded to ensure all in attendance are on the record and review the structure of the notes to ensure all items discussed are captured.
- Review the shared drive on the practice computer system to ensure the latest policies are accessible to staff.
- Consider risk assessments in relation to the security of the premises.
- Consider confidentiality at the front desk with regard to patients approaching the desk on an individual basis.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice