The Care Quality Commission
  • Doctor
  • GP practice

Archived: The Surgery

Overall: Good read more about inspection ratings

28 Holes Lane, Woolston, Warrington, Cheshire, WA1 4NE (01925) 599855

Provided and run by:
Drs M A Cardwell, M R Wadsworth, N M Iceton, Q I Chuka

All Inspections

03/02/2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Surgery on 23 March 2016. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for The Surgery on our website at www.cqc.org.uk.

At our previous inspection on 23 March 216 we rated the practice as ‘good’ overall but as ‘requires improvement’ for providing a safe service as we identified breaches of Regulations 16 and 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider did not have a robust system in place for recording, investigating and taking action in response to significant events. The procedures for managing complaints also required improvement to ensure; patients were provided with accessible and accurate information about how to make a complaint, that all complaints were fully investigated in a timely manner and action was taken to prevent a re-occurrence.

This inspection was a desk-based review carried out on 3 February 2017 to confirm that the provider had carried out their plan to meet the legal requirements in relation to the breaches in regulation identified at our previous inspection. This report covers our findings in relation to that and additional improvements made since our last inspection.

The findings of this inspection were that the provider had taken action to meet the requirements of the last inspection and the service is now rated as good for providing safe services. Our key findings were as follows:

  • The provider has taken action to review the processes in place for managing significant events. There is now a more robust system in place for recording, investigating and taking action in response to significant events and for oversight and review of events.

  • The complaints procedure had been reviewed and updated. Information provided to patients had been reviewed to include details about the different options for making a complaint and the stages of this. Systems for the oversight of complaints had been introduced including ensuring appropriate timescales were in place for responding to complaints. Complaints were discussed at regular clinical meetings and a review of complaints was carried out on a bi-annual basis.

The provider had also made a number of improvements where we had identified these at our last inspection. These included;

  • A risk assessment had been carried with regards to whether or not staff required a Disclosure and Barring Service (DBS) check linked to their roles and responsibilities.

  • The process for referring patients to secondary care for tests or treatments had been reviewed. The provider had designated additional staffing to improve the efficiency of the referrals process.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

23/03/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Surgery on 23 March 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 report incidents and near misses. However, the practice was not always demonstrating that they were fully investigating events and taking action in response to the learning from these.
  • Systems were in place to deal with medical emergencies and staff were trained in basic life support.
  • There were systems in place to reduce risks to patient safety. For example, infection control practices were good and there were regular checks on the environment and on equipment used.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Feedback from patients about the care and treatment they received from clinicians was very positive.
  • Data showed that outcomes for patients at this practice were similar to outcomes for patients locally and nationally.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Staff felt well supported in their roles and were kept up to date with appropriate training.
  • Patients said they were treated with dignity and respect and they were involved in decisions about their care and treatment.
  • Patients gave us positive feedback about the appointments system. The majority of patients we spoke with told us they could get through to the practice by phone easily and they could get a routine or urgent appointment when they needed one.
  • The practice had good facilities, including disabled access. It was well equipped to treat patients and meet their needs.
  • Information about services and how to complain was available but some of this needed updating. The majority of complaints had been investigated and responded to in a timely manner, but we saw a small number that required timely investigation and action to prevent re-occurrence. These were linked to significant events.
  • There was a clear leadership and staff structure and staff understood their roles and responsibilities.
  • The practice provided a range of enhanced services to meet the needs of the local population.
  • The practice sought patient views about improvements that could be made to the service. This included the practice having and consulting with a patient participation group (PPG).

The areas where the provider must make improvement are:

  • The provider must ensure a robust system is in place for recording, investigating and taking action in response to significant events.

  • The provider must make improvements to the complaints process to ensure; patients are provided with accessible and accurate information about how to make a complaint and the various stages of this, all complaints are fully investigated in an appropriately timely manner and action is taken to prevent a re-occurrence.

The areas where the provider should make improvement are:

  • Introduce a protocol and guidance for reception staff in dealing with appointment requests.

  • Carry out a risk assessment to support the decision not to carry out DBS checks for all staff and review the role of staff that have not had a DBS check as part of this.

  • Review the process for referring patients to secondary care for tests or treatments to ensure the referrals are timely.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice