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<Location name here> Quality report

<Add address here> Tel: <xxxx xxxxx xxxxxx> <www.xxxxxxxxxxxxxxxx>

Date of inspection visit: <xxxx>

Date of publication: <xxxx>

This report describes our judgement of the quality of care at this service. It is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information given to us from the provider, patients, the public and other organisations.

Overall rating for this location: Dictate a Rating (Dictate a rating: Outstanding, good, requires

improvement or inadequate)

Rating by key question:(Dictate a rating: Outstanding, good, requires


Are services at this location safe? Dictate a Rating Are services at this location effective? Dictate a Rating Are services at this location caring? Dictate a Rating Are services at this location responsive? Dictate a Rating Are services at this location well-led? Dictate a Rating

<Copy ratings dots from >

PMS report template (Product ID: 900031) v151

Overall Summary


Letter from the Chief Inspector of General PracticeInclude the following details in the introductory paragraphs:

- Date of inspection- Type of inspection (E.g. comprehensive, focused)

If there are any services operated by the provider which were not inspected as part of this visit, please ensure this is made clear here e.g. branch or satellite services.

Include an overall statement referencing the overall rating, and if appropriate some of the notable ratings underpinning it.

Our key findings were as follows: Findings Findings Findings

The key findings should always include elements that research has shown to be highly valued among the public. In this case, access to the service/GP, safe systems, infection control, treated with kindness and respect, communication.

We saw several areas of outstanding practice including: Outstanding practice Outstanding practice

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must: Action Action

Please ensure the above details recorded under the MUST criteria are accompanied by a regulatory action and consistent with the details included in the ‘areas for improvement’ section at the end of this report.

In addition the provider should:

Action Action

If a recommendation to place the provider into special measures is made, insert the following sentence after the factual accuracy period has passed: On the basis of this inspection, I have recommended that the provider be placed into special measures.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice



Page

Summary of this inspectionPMS report template (Product ID: 900031) v15

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Contents


Letter from the Chief Inspector of General Practice 2

The five questions we ask and what we found 3

The six population groups and what we found x

What people who use the service say x

Areas for improvement x

Outstanding practice x

Detailed findings from this inspectionOur inspection team x

Background to the service x

Why we carried out this inspection x

How we carried out this inspection x

Detailed findings x

Action we have told the provider to take x

Summary of findingsPMS report template (Product ID: 900031) v15

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We always ask the following five questions of services. (Dictate a rating: Outstanding, good, requires improvement or inadequate)

Are services safe? Dictate a Rating

<Insert a paragraph that summarises findings for this domain>

Please note: This section will be used to populate the CQC website.

Are services effective? Dictate a Rating



Are services caring? Dictate a Rating

<Insert a short paragraph that summarises findings for this domain>


Are services responsive to people’s needs? Dictate a Rating



Are services well-led? Dictate a Rating



Summary of findings


The five questions we ask and what we found


We always inspect the quality of care for these six population groups. (Dictate a rating: Outstanding, good, requires


Older people Dictate a Rating <Insert a paragraph that summarises findings for this population group. Ensure this clearly describes the quality of care at the service and what it means for patients in this population group> Please note: This section will be used to populate the CQC website.

People with long-term conditions Dictate a Rating <Insert a paragraph that summarises findings for this population group. Ensure this clearly describes the quality of care at the service and what it means for patients in this population group> Please note: This section will be used to populate the CQC website.

Families, children and young people Dictate a Rating <Insert a paragraph that summarises findings for this population group. Ensure this clearly describes the quality of care at the service and what it means for patients in this population group> Please note: This section will be used to populate the CQC website.

Working age people (including those recently retired and students) Dictate a Rating

<Insert a paragraph that summarises findings for this population group. Ensure this clearly describes the quality of care at the service and what it means for patients in this population group>


People living in vulnerable circumstances Dictate a Rating <Insert a paragraph that summarises findings for this population group. Ensure this clearly describes the quality of care at the service and what it means for patients in this population group>


People experiencing poor mental health (including people with dementia) Dictate a Rating

<Insert a paragraph that summarises findings for this population group. Ensure this clearly describes the quality of care at the service and what it means for patients in this population group>



The six population groups and what we found (Delete this section if OOH)


<Provide a summary of results from patient surveys / comment cards / feedback.

Do not include direct “quotes” from patients you spoke with during the inspection. State how many comment cards were completed and the number of patients who completed surveys etc.

Action the provider MUST take to improve

<Provide a summary of actions the service MUST take> Note: detailed actions will be written in detailed findings section of the report.

NB. If no breaches have occurred, please remove this section from the report.

Action the provider SHOULD take to improve

< Even if the provider is compliant, you can still make comments that may be useful to the provider and to the public about where improvements should be made> Provide a summary of actions the service SHOULD take.

Note: detailed actions will be written in detailed findings section of the report.

NB. If no areas for improvement apply, please remove this section from the report.


What people who use the service say

Areas for improvement


<Provide a summary of any ‘outstanding’ practice> Note: detailed findings will be written in detailed findings section of the report.

NB: If no outstanding areas apply, please remove this section from the report.


Outstanding practice


<Location name> Detailed findings

Our inspection team

<Include the job title & experiences of people who made up the inspection team at this location.

For example:Our inspection team was led by a CQC Lead Inspector. The team included a GP, CQC inspectors and a variety of specialists: <Insert details of their specialisms.> Ensure you describe them accurately.

You should also be aware that experts who take part in the inspections, for example, Experts by Experience, are not independent individuals who accompany an inspection team – they are a part of the inspection team and should be described in that way. They are granted the same authority to enter registered persons’ premises as the CQC inspectors.>

Background to <insert name of location>

<Provide an overview of the location (e.g. area, size, facilities, number and demographics of people using services, number of staff and roles (including number of partners, salaried GPs, WTE, GP sessions, nurses etc)). State the mix of GPs and practice nurses e.g. 1 male and 2 female or all male or all female. State whether a training practice.

Include details of the practice contract e.g. GMS, PMS, APMS.

Include information about previous performance and any concerns that may have led to the consideration of an inspection visit. Include the chronology of any regulatory action and links to any previous reports that may be relevant. The majority of this information should come from the data pack. Please note: you can use present tense here to describe the background.

Please make sure you check the provider website against the information you obtain.

Please enter here all the sites/addresses where regulated activities are provided from this location (state whether visited as part of the inspection or not).

Please state here whether the practices have opted in or opted out of providing out-of-hours services to their own patients>



Why we carried out this inspection For example:

We inspected this service as part of our new comprehensive inspection programme. This provider had not been inspected before and that was why we included them – do not include, if this statement does not apply. Include any other information which is relevant.

How we carried out this inspection

Summarise the inspection process, including the activities carried out by those involved, how the location was reviewed and on what basis, and the methods used to gather information from people who use services and staff as well as others e.g. LMCs, LHW, HOSC, etc. Include the following details:

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

Is it safe? Is it effective? Is it caring? Is it responsive to people’s needs? Is it well-led?

<Delete the text below about the population groups if this is an OOHs inspection>We also looked at how well services are provided for specific groups of people and what good care looks like for them. The population groups are:

Older people People with long-term conditions Families, children and young people Working age people (including those recently retired and students) People living in vulnerable circumstances People experiencing poor mental health (including people with dementia)

For example:‘Before visiting, we reviewed a range of information we hold about the practice and asked other organisations to share what they knew. We carried out an announced visit on 5 and 8 October 2013. During our visit we spoke with a range of staff (insert job roles of staff) and spoke with patients who used the service. We observed how people were being cared for and talked with carers and/or family members and reviewed personal care or treatment records of patients. We held a listening event/reviewed comment cards where patients and members of the public shared their views and experiences of the service.’



Are services safe? Dictate a Rating (Dictate a rating: Outstanding, good, requires


Our findings <Set out a concise analysis of the evidence that best supports your findings around the key question of 'safe'. Use sub headings to structure your findings (see below). Statements should describe the effects on people who use the service and should encompass risks to patients and others.>

<Include details of findings for each population group within this section>

Subheadings:

Safe Track Record

<Please describe evidence obtained for KLOE S1>

Learning and improvement from safety incidents


Include the following sentence and add any relevant details about the system in place:

The Practice has a system in place for reporting, recording and monitoring significant events.

Reliable safety systems and processes including safeguarding




Include information on chaperone policy here.

Include the level of safeguarding training which GPs had completed

Medicines Management


If issues/concerns are identified with medicines management, please state here: The practice must improve the way they manage medicines.

Cleanliness & Infection Control


Insert details of whether Legionella testing carried out here.

Equipment


Staffing & Recruitment


Include whether they had an SLA with a locum agency (if they used locums)

Monitoring Safety & Responding to Risk


Arrangements to deal with emergencies and major incidents




Are services effective? Dictate a Rating (Dictate a rating: Outstanding, good, requires


(For example, treatment is effective)

Our findings <Set out a concise analysis of the evidence that best supports your findings around the key question of 'effective'. Use sub headings to structure your findings (see below). Statements should describe the effects on people who use the service and should encompass risks to patients and others.>


Subheadings:

Effective needs assessment <Please describe evidence obtained for KLOE E1>

Management, monitoring and improving outcomes for people <Please describe evidence obtained for KLOE E2>

If relevant include the following sentence:The Practice has a system in place for completing clinical audit cycles. Examples of clinical audits included……>(The following is an example:Doctors in the surgery undertake minor surgical procedures in line with their registration and NICE guidance. The staff are appropriately trained and keep up to date. They also regularly do clinical audits on their results and use that in their learning).

Effective staffing <Please describe evidence obtained for KLOE E3>

Check all staff up to date with revalidations and insert here.

Working with colleagues and other services <Please describe evidence obtained for KLOE E4>

Include what systems are in place for managing blood results and recording information from other health care providers i.e. discharge letters / notifications.

Information Sharing <Please describe evidence obtained for KLOE E5>

Consent to care and treatment <Please describe evidence obtained for KLOE E6>



Health Promotion & Prevention <Please describe evidence obtained for KLOE E7>

Insert details of new patient checks here, e.g. All new patients are offered a consultation…

Are services caring? Dictate a Rating (Dictate a rating: Outstanding, good, requires


Our findings <Set out a concise analysis of the evidence that best supports your findings around the key question of 'caring'. Use sub headings to structure your findings (see below). Statements should describe the effects on people who use the service and should encompass risks to patients and others. Please insert information about patient satisfaction in this domain.>


Subheadings:

Respect, Dignity, Compassion & Empathy <Please describe evidence obtained for KLOEs C1,2 & C3>

Care planning and involvement in decisions about care and treatment <Please describe evidence obtained for KLOE C2>

Patient/carer support to cope emotionally with care and treatment <Please describe evidence obtained for KLOE C3>



Are services responsive to people’s needs?

Dictate a Rating (Dictate a rating: Outstanding,

good, requires improvement or inadequate)

(For example, to feedback?)

Our findings <Set out a concise analysis of the evidence that best supports your findings around the key question of 'responsive'. Use sub headings to structure your findings (see below). Statements should describe the effects on people who use the service and should encompass risks to patients and others. Please insert information about patient participation groups (PPG) in this domain.>


Subheadings:

Responding to and meeting people’s needs <Please describe evidence obtained for KLOE R1> Insert how the practice responded to information from PPG and actions taken.

Tackling inequity and promoting equality <Please describe evidence obtained for KLOE R2>

Access to the service <Please describe evidence obtained for KLOE R3>

Listening and learning from concerns & complaints <Please describe evidence obtained for KLOE R4>

Include this sentence:



The practice have a system in place for handling complaints and concerns. Their complaints policy is in line with recognised guidance and contractual obligations for GPs in England and there is a designated responsible person who handles all complaints in the practice.You can then summarise how the system is working.

Are services well-led? Dictate a Rating (Dictate a rating: Outstanding,

good, requires improvement or inadequate)

(For example, are they well-managed and do senior leaders listen, learn and take appropriate action?)

Our findings <Set out a concise analysis of the evidence that best supports your findings around the key question of 'well-led'. Use sub headings to structure your findings (see below). Statements should describe the effects on people who use the service and should encompass risks to patients and others. Please insert information about productive general practice programme in this domain.>


Subheadings:

Vision and Strategy <Please describe evidence obtained for KLOE W1>

Governance Arrangements <Please describe evidence obtained for KLOE W2>

Leadership, openness and transparency <Please describe evidence obtained for KLOE W3>



Note: Please state whether the provider is subject to external peer review (for example; a member of Urgent Health UK (UHUK))

Practice seeks and acts on feedback from users, public and staff <Please describe evidence obtained for KLOE W4>

Insert how PPG used and information received from PPG.

Management lead through learning & improvement <Please describe evidence obtained for KLOE W5>



This section is primarily information for the provider

Compliance actionsAction we have told the provider to takeThe table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards.

Regulated activity Regulation <Insert regulated activity, e.g. TDDI or diagnostic & screening>

<Insert the relevant regulation and justification of how it was not being met. For example: Regulation 15 Health & Social Care Act 2008 (Regulated Activities) Regulations 2010 Safety and Suitability of Premises.

How the regulation was not being met: People who use services and others were not protected against the risks associated with unsafe or unsuitable premises because of inadequate maintenance. Regulation 15 (1) (c).>


<Insert the relevant regulation and justification of how it was not being met.>





This section is primarily information for the provider

Enforcement actionsAction we have told the provider to takeThe table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards.


<Insert the relevant regulation and justification of how it was not being met. For example: Regulation 15 Health & Social Care Act 2008 (Regulated Activities) Regulations 2010 Safety and Suitability of Premises.

How the regulation was not being met: For example: People who use services and others were not protected against the risks associated with unsafe or unsuitable premises because of inadequate maintenance. Regulation 15 (1) (c).>






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PMS report template dragon enabled - WhatDoTheyKnow · Web viewWhen deleting as appropriate, please say the word you wish to use and the alternatives will be deleted PMS report template