9 March 2017
During an inspection looking at part of the service
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at South Park Surgery on 22 September 2016. During this inspection we found breaches of legal requirement and the provider was rated as requires improvement under the safe, caring and responsive domains. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for South Park Surgery on our website at www.cqc.org.uk.
Following this inspection the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:
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Reviewing and continuing to take action in addressing areas that are lower than average for patients with long term conditions in relation to local CCG and national averages.
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Reviewing access to appointments in line with patient feedback regarding this aspect and areas of patient satisfaction within the National GP Patient survey.
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Implementing and maintaining a recording system to track prescription forms and pads.
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Reviewing their recruitment process to ensure all pre-employment checks are completed before employment commences
Additionally we had found that:
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The practice needed to review their procedure for patients that do not respond to their invitation for cervical screening.
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The practice needed to review their procedure for patients that do not attend for breast or bowel cancer screening.
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The practice needed to continue in their attempt to obtain an electrical installation certificate for the practice building.
This inspection was an announced focused inspection carried out on 9 March 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. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is still rated as requires improvement.
Our key findings were as follows:
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The practice was now complying with their practice recruitment policy and had obtained retrospective references for staff that were working within the practice. No new staff had started employment since our last inspection.
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The practice had reviewed their procedure for patients that had not attended for cervical, breast or bowel cancer screening. The practice now contacted these patients and invited them to contact the practice to discuss any concerns they may have. Data from 2015/16 showed the practice achieved similar results as recorded by both local Clinical Commissioning Group (CCG) and national averages for both breast and bowel cancer screening. The practice had achieved 70% for cervical cancer screening which was lower than both local CCG and national averages of 80% and 81% respectively.
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The practice had employed an external contractor to undertake an electrical installation assessment. This was undertaken in February 2017. There were identified areas of required work outstanding at the time of this inspection.
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There had been no update in the national GP patient survey since our last inspection and the practice had not undertaken any internal patient surveys. Evidence was seen on NHS choices of 10 reviews which were of mixed feedback.
However, there were also areas of practice where the provider needs to make improvements.
Importantly, the provider must:
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Review access to appointments in line with patient feedback regarding this aspect and other areas of low patient satisfaction documented within the National GP Patient survey and detail their action plan to resolve these issues.
In addition the provider should:
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Continue to monitor patient reviews of those suffering long term conditions.
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Monitor their prescription form tracking process throughout the practice to ensure that this is adequate.
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Continue to monitor the procedure in place to ensure that patients invited to attend for cancer screening are contacted to assist in increasing their attainment level in line with both local CCG and national averages.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice