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Inspection carried out on 18 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Enys Road Surgery was previously inspected in August 2015 and was rated good in all domains and overall.

At this inspection in December 2017 the practice is rated as Good overall.

The key questions are rated as:

Are services safe? – Requires Improvement

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 with dementia) - Good

We carried out an announced comprehensive inspection at Enys Road Surgery on 18 December 2017 as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

  • 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.

  • The practice operated a ‘traffic light’ system for patients who were high risk and needed a prompt response if they requested help.

  • They practice offered an afternoon walk-in service for registered patients with urgent concerns.

  • Staff involved and treated patients with compassion, kindness, dignity and respect.

  • The practice encouraged patient feedback and responded positively to patient needs.

  • There was a strong focus on continuous learning and improvement at all levels of the organisation. The practice taught external practitioners from several clinical disciplines and encouraged learning and improvement within their own staff.

The areas where the provider must make improvements as they are in breach of regulations are:

Establish effective systems and processes to ensure that care and treatment is provided in a safe way for service users. By:-

  • Ensuring that the fire risk assessment is updated and all actions taken recorded.

  • Ensuring all outstanding electrical work is completed.

The areas where the provider should make improvements are:

  • Review how GP registration is recorded and monitored on an ongoing basis.

  • Consider having a GP check prescriptions issued, but not picked up by patients before destroying them.

  • To adhere to the recruitment policy on all occasions.

  • Review the low uptake of pneumococcal booster vaccine for children aged two.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 18 August 2015

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

 

We carried out an announced comprehensive inspection of this practice on 2 December 2014.

Breaches of legal requirements were found during that inspection within the safe domain. After the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the legal requirements in relation to the following:

  • The practice must ensure that all staff are trained in safeguarding of vulnerable adults.
  • The practice must ensure staff have appropriate policies and procedures for safeguarding vulnerable adults.
  • The practice must ensure criminal record checks are undertaken via the Disclosure and Barring Service for staff trained to provide chaperone services.
  • The practice must ensure all remedial works and on-going monitoring recommendations are implemented in order to reduce the risk of exposure of staff and patients to legionella bacteria.

We undertook this focused inspection on 18 August 2015 to check that the provider had implemented their action plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

Our key findings across the areas we inspected were as follows:-

  • The practice had ensured that all staff were trained in safeguarding of vulnerable adults and we saw training certificates for staff which confirmed this to be the case. We saw that the practice manager was monitoring time frames for training and had maintained a comprehensive training record for all staff.
  • The practice had ensured that staff had appropriate policies and procedures for safeguarding vulnerable adults. We viewed the policies and procedures and staff we spoke with demonstrated an understanding of how these were applied to their practice.
  • The practice had ensured criminal record checks were undertaken via the Disclosure and Barring Service for staff trained to provide chaperone services. We viewed risk assessments and DBS records which confirmed this action had been carried out.
  • The practice had ensured all remedial works had been carried out and that on-going monitoring recommendations were implemented in order to reduce the risk of exposure of staff and patients to legionella bacteria. We saw that action had been taken to implement a system of monitoring and that the works had been carried out.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 2 December 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Enys Road Surgery was previously inspected in August 2015 and was rated good in all domains and overall.

At this inspection in December 2017 the practice is rated as Good overall.

The key questions are rated as:

Are services safe? – Requires Improvement

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 with dementia) - Good

We carried out an announced comprehensive inspection at Enys Road Surgery on 18 December 2017 as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

  • 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.

  • The practice operated a ‘traffic light’ system for patients who were high risk and needed a prompt response if they requested help.

  • They practice offered an afternoon walk-in service for registered patients with urgent concerns.

  • Staff involved and treated patients with compassion, kindness, dignity and respect.

  • The practice encouraged patient feedback and responded positively to patient needs.

  • There was a strong focus on continuous learning and improvement at all levels of the organisation. The practice taught external practitioners from several clinical disciplines and encouraged learning and improvement within their own staff.

The areas where the provider must make improvements as they are in breach of regulations are:

Establish effective systems and processes to ensure that care and treatment is provided in a safe way for service users. By:-

  • Ensuring that the fire risk assessment is updated and all actions taken recorded.

  • Ensuring all outstanding electrical work is completed.

The areas where the provider should make improvements are:

  • Review how GP registration is recorded and monitored on an ongoing basis.

  • Consider having a GP check prescriptions issued, but not picked up by patients before destroying them.

  • To adhere to the recruitment policy on all occasions.

  • Review the low uptake of pneumococcal booster vaccine for children aged two.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

CQC Insight

These reports bring together existing national data from a range of indicators that allow us to identify and monitor changes in the quality of care outside of our inspections. The data within the reports do not constitute a judgement on performance, but inform our inspection teams. Our judgements on quality and safety continue to come only after inspection and we will not make judgements on data alone.