ILLUSTRATIVE GP REPORT – May 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, even for a ‘good’ service, you will need to ensure that the illustrative text is appropriately tailored to the provider.
You should carefully proof read each completed section to ensure that what you have written is tailored, accurate and coherent.
This is an updated version of the illustrative report and reflects comments and feedback received since January 2015. Most of the changes are minor. The most significant change is greater use of data, using the version of the data pack updated in May 2015 and highlighting where this can be best used in your reports. Changes made to the GP template report from January 2015 to April 2015 are also reflected in this version.
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.
Specifically, we found the practice to be outstanding for providing responsive and effective services and for being well led. It was also outstanding for providing services for the [list population groups where o/s]. It was good for providing caring and safe services.
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].
· Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.
· The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet people’s needs.
· 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 (PPG).
· 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. A business plan was in place, was monitored and regularly reviewed and discussed with all staff. High standards were promoted and owned by all practice staff with evidence of team working across all roles.
We saw several areas of outstanding practice including:
· The practice had increased the flexibility of access to appointments and could demonstrate the impact of this by reduced use of the out of hours service and very positive patient survey results.
· The practice had a very good skill mix which included advanced nurse practitioners (ANPs) and was able to see a broader range of patients than the practice nurses. There was a preceptorship programme in place to support new ANPs to the practice.
· The practice had reached out to the local community by approaching mosques, churches and schools and had attended them to promote better health. If any underlying health issues were identified the patients (if they belonged to the practice) were offered an appointment at the practice and patients from other practices were advised to attend their own GP.
· The practice had a health trainer to support weight management, alcohol reduction and smoking cessation and could demonstrate this had a positive impact for patients using this service.
However there were areas of practice where the provider needs to make improvements
Importantly the provider should [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.
Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for the [list population groups where good]. It required improvement for providing safe services.
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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
· Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
· Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
· 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.
We saw one area of outstanding practice:
· The practice provided general health advice including a sexual health clinic to young people at the local college. In addition a drop in clinic was available to young people registered with the practice where they could receive health advice or treatment including sexual health services.
However there were areas of practice where the provider needs to make improvements.
Importantly the provider must/should [include as needed]
· Ensure recruitment arrangements include all necessary employment checks for all staff.
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.
Specifically, we found the practice to require improvement for providing safe, effective, responsive and well led services. It also required improvement for providing services for the [list population groups where requires improvement]. It was good for providing a caring service.
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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
· Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
· Data showed patient outcomes were average for the locality. Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
· 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.
· Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments.
· The practice had a number of policies and procedures to govern activity, but these were over five years old and had not been reviewed since. The practice did not hold regular governance meetings and issues were discussed at ad hoc meetings.
· The practice had not proactively sought feedback from staff or patients.
The areas where the provider must make improvements are: [include as needed]
· Ensure recruitment arrangements include all necessary employment checks for all staff.
· Ensure audits of practice are undertaken, including completed clinical audit cycles.
· Ensure there are formal governance arrangements in place and staff are aware how these operate.
· Ensure all staff have appropriate policies, procedures and guidance to carry out their role.
· Ensure there are mechanisms in place to seek feedback from staff and patients and this feedback is responded to.
In addition the provider should: [include as needed]
· Improve the availability of non-urgent appointments.
If there are any areas rated as inadequate, please state the following here;
Where, as in this instance, a provider is rated as inadequate for one of the five key questions or one of the six population groups it will be re-inspected no longer than six months after the initial rating is confirmed. If, after re-inspection, it has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place it into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.
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.
Specifically, we found the practice inadequate for providing safe and effective services and being well led. It was also inadequate for providing services for the [list population groups where inadequate]. Improvements were also required for providing responsive services. It was good for providing caring services.
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]
· 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.
· There was insufficient assurance to demonstrate people received effective care and treatment. For example [xxx].
· Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
· Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments and that it was very difficult to get through the practice when phoning to make an appointment.
· 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]
· 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.
· Ensure audits of practice are undertaken, including completed clinical audit cycles.
· Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision.
· Ensure staff have 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]
· Improve processes for making appointments.
If placed into special measures
On the basis of the ratings given to this practice at this inspection, (and the concerns identified at xxx previous inspections add if applicable), I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
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