The Elms Surgery

We carried out an announced comprehensive inspection at The Elms Surgery on 28 November 2022. Overall, the practice is rated as requires improvement.

The ratings for each key question are:

• Safe - requires improvement.
• Effective – requires improvement.
• Caring – good.
• Responsive – good.
• Well-led – requires improvement.

Following our previous inspection on 19 January 2017, the practice was rated good overall and for all key questions and population groups.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Elms Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

The Elms Surgery registered a different location with CQC in September 2018. This was our first inspection of the service since the practice had moved location.

We inspected The Elms Surgery as part of our regulatory functions under the Health and Social Care Act 2008.

We carried out this inspection to check the service was providing safe, effective, caring, responsive and well-led services from the new location. The inspection therefore focused on all of these key questions. The inspection included a review of areas where the provider should make improvements that had been identified at our last inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• conducting staff interviews using video conferencing facilities
• completing clinical searches and reviewing patient records on the practice’s patient records system to identify issues and clarify actions taken by the provider
• requesting evidence from the provider
• a site visit
• requesting and reviewing feedback from staff and patients who work at or use the service.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services
• information from the provider, patients, the public and other organisations.

We found that:

• The practice had not always identified and managed risks effectively to keep patients and staff safe and protected from avoidable harm. For example, in relation to safeguarding adults and children, infection prevention and control, medical emergencies, fire safety, recruitment checks, staff vaccinations and the safe and appropriate use of medicines.

• Not all clinical staff felt they had the support they needed when they needed it, for example to discuss more complex patients and share learning.

• People were supported to live healthier lives and were involved in managing and improving their own health. More patients felt they were involved in decisions about their care and treatment as much as they wanted to be than at our last inspection.

• The number of patients screened for cervical cancer remained below the national target.

• Patients told us staff treated them with kindness, compassion, dignity and respect.

• Patients could access care and treatment in a timely way. More patients said it was easy to get through to the practice by telephone and were satisfied with the appointment times available at The Elms Surgery than the average for the area or for England.

• The way the practice was led and managed meant not all staff were aware of the practice’s values and vision or understood their role in achieving them. Not all staff felt they were involved in the development of the practice or that they had opportunity to share their views about the planning and delivery of services.

• Not all staff were aware of who the practice’s Freedom to Speak Up Guardian was or how they could contact them if they needed to.

• Policies and procedures had not always been updated to show changes made, for example in relation to fire procedures.

• Leaders were not always clear about the practice’s requirements and documents sometimes gave differing information about how often tests of systems and staff training should be completed, for example in relation to fire safety.

We found a breach of regulations. The provider must:

• establish and operate effective systems and processes to make sure they meet the fundamental standards of care.

More detail is contained in the requirement notice section at the end of this report.

We also found the following areas where the provider could improve and should:

• continue to monitor, and take actions to improve, the uptake of childhood immunisations

• consider different ways for people to provide feedback about the service, including complaints and patient surveys, and take action to make it easy for people to do so

• take steps to improve staffs’ knowledge of the Freedom to Speak Up Guardian and how to contact them if needed

• take steps to improve access to information, for example for carers, on the practice’s website

• identify and support carers.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services