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Inspection carried out on 2 August 2016

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

Letter from the Chief Inspector of General Practice

When we visited Underwood Surgery in January 2016 we found concerns, related to the safe delivery of services. The practice was rated as requires improvement for safe and good for effective, caring, responsive and well led. Overall the practice was rated as good.

We found that the practice required improvement for the provision of safe services because improvements were needed in the way the practice assessed, managed and mitigated the risks associated in relation to safeguarding and non-clinical staff performing chaperone duties.

Underwood Surgery sent us an action plan that set out the changes they would make to improve these areas.

We visited the practice to undertake a focused inspection on 2 August 2016 to ensure the practice had made these changes and that the service was meeting regulations. At this inspection we rated the practice as good for providing safe services. The overall rating for the practice remains good. For this reason we have only rated the location for the key question to which this related. This report should be read in conjunction with the full inspection report of 14 January 2016.

Our key findings were:

  • The practice had robust processes in place to identify and protect vulnerable adults and children who could be at risk.
  • The practice had put in place procedures to ensure risks were mitigated in relation to non-clinical staff performing chaperone duties.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 14 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Underwood Surgery on 14 January 2016. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, there was a lack of evidence of learning from reported incidents.
  • Risks to patients were not always assessed and well managed, for example the providers chaperone policy and fire safety.
  • There were inconsistencies and lack of scrutiny and oversight in the arrangements to safeguard children and vulnerable adults from abuse.
  • 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.
  • Urgent appointments were available on the day they were requested.

The areas where the provider must make improvements are:

  • Establish and operate an effective system to assess, manage and mitigate the risks associated in relation to safeguarding.

  • Establish and operate an effective system to assess, manage and mitigate the risks associated in relation to non clinical staff performing chaperone duties.

In addition the provider should:

  • Review arrangements for identification of carers.

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.


Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.