ILLUSTRATIVE GP REPORT – December 2015
GUIDANCE FOR USE
This illustrative text is intended to help you draft your report by providing examples of how and where to present your evidence, what evidence you could include and to indicate the level of detail needed in your report.
You should use this text to help you write your reports, amending it to include the specific evidence, findings and examples you find on your inspection. This will mean adding and deleting as appropriate to ensure that all relevant evidence is included in each section and that the final text accurately reflects your findings and conclusions. The text in italics prompts you to add the specific examples you found. These also include examples of population group evidence you can draw on to support your judgements.
In general, the illustrative text in the detailed findings section of the report describes a ‘good’ provider. However, experience has shown that the text, appropriately tailored, can form the basis for ‘outstanding’, ‘requires improvement’ or ‘inadequate’ ratings. Even for a ‘good’ service, you will need to ensure that the illustrative text is appropriately tailored to the provider.
Where you find breaches of a regulation, you need to ansure that the report contains enough evidence to make it clear how the regulation was breached.
You should carefully proof read each completed section to ensure that what you have written is tailored, accurate and coherent.
In most cases, percentages should be rounded to whole numbers (ie do not include decimal places).
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: / Choose a rating / lRating by key question:
Are services at this location safe?
accident and emergency / Choose a rating / l
Are services at this location effective? / Choose a rating / l
Are services at this location caring? / Choose a rating / l
Are services at this location responsive? / Choose a rating / l
Are services at this location well-led? / Choose a rating / l
<Copy ratings dots from ¶l l l
OUTSTANDINGWe carried out an announced comprehensive inspection at XXXX on XX XXX. Overall the practice is rated as outstanding.
Our key findings across all the areas we inspected were as follows: [only select those that are relevant/add in your key findings as appropriate]
· Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
· The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example <XXX>.
· Feedback from patients about their care was consistently and strongly positive.
· The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs. For example <XXX>
· The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. For example <XXX>
· The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand
· The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.
We saw several areas of outstanding practice including:
[include a brief description of the outstanding practice found, including information about impact or outcomes as appropriate)
However there were areas of practice where the provider should make improvements:
[include as needed - practice can still be outstanding with shoulds].
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
GOOD
We carried out an announced comprehensive inspection at XXXX on <XX XXX. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows: [only select those that are relevant/add in your key findings as appropriate]
· 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 compassion, dignity and respect and they were involved in their care and decisions about their 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 and complied with the requirements of the Duty of Candour.
We saw one area of outstanding practice:
[include a brief description of the outstanding practice found, including information about impact or outcomes as appropriate)
The areas where the provider should/must make improvement are: [include as needed]
[include a brief description as needed]
If coming out of special measures:
I confirm that this practice has improved sufficiently to be rated ‘Good’ overall. The practice will be removed from special measures.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
REQUIRES IMPROVEMENT
We carried out an announced comprehensive inspection at XXXX on XX XXX. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows: [only select those that are relevant/add in your key findings as appropriate]
· Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not thorough enough. Patients did not always receive a verbal and written apology.
· Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
· Data showed patient outcomes were low compared to the locality and nationally. Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
· The majority of patients said they were treated with compassion, dignity and respect. However, not all felt cared for, supported and listened to.
· Information about services was available but not everybody would be able to understand or access it. For example, there were no information leaflets available in Polish despite there being a large number of Polish patients on the practice list.
· Urgent appointments were usually available on the day they were requested.
· The practice had a number of policies and procedures to govern activity, but some were overdue a review.
· The practice had proactively sought feedback from patients and had an active patient participation group.
The areas where the provider must make improvements are: [include as needed – do not include regulation numbers]
· Investigate safety incidents thoroughly and ensure that people affected receive reasonable support and a verbal and written apology.
· Ensure recruitment arrangements include all necessary employment checks for all staff.
· Carry out clinical audits and re-audits to improve patient outcomes.
In addition the provider should: [include as needed – do not include regulation numbers]
· Improve the availability of non-urgent appointments.
· Provide practice information in appropriate languages and formats.
· Review and update procedures and guidance.
If there are any areas rated as inadequate, please state the following here;
Where a practice is rated as inadequate for one of the five key questions or one of the six population groups the practice will be re-inspected within six months after the report is published. If, after re-inspection, the practice has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place the practice into special measures. Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.
If going into special measures via ‘slow route’ please state the following here:
I am placing this practice in special measures. Where a practice is rated as inadequate for one of the five key questions or one of the six population groups and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.
Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve.
The practice will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service..
Special measures will give people who use the practice the reassurance that the care they get should improve.
If coming out of special measures:
I confirm that this practice has improved sufficiently to be rated ‘Requires improvement’ overall. The practice will be removed from special measures.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
INADEQUATE
We carried out an announced comprehensive inspection at XXXX on XX XXX. Overall the practice is rated as inadequate.
Our key findings across all the areas we inspected were as follows: [only select those that are relevant/add in your key findings with a very brief example to illustrate as appropriate]
· Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment and actions identified to address concerns with infection control practice had not been taken. Add in other examples here <XXX>.
· Staff were not clear about reporting incidents, near misses and concerns and there was no evidence of learning and communication with staff.
· Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.
· Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
· Appointment systems were not working well so patients did not receive timely care when they needed it.
· The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.
The areas where the provider must make improvements are: [include as needed – do not include regulation numbers]
· Introduce robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.
· Take action to address identified concerns with infection prevention and control practice.
· Ensure recruitment arrangements include all necessary employment checks for all staff.
· Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines.
· Carry out clinical audits including re-audits to ensure improvements have been achieved.
· Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
· Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
· Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements
The areas where the provider should make improvement are: [include as needed – do not include regulation numbers]
· Improve processes for making appointments.
If placed into special measures
I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.
The practice will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service.
Special measures will give people who use the practice the reassurance that the care they get should improve.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
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Summary of this inspection
Letter from the Chief Inspector of General Practice x