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Review carried out on 31 August 2019

During an annual regulatory review

We reviewed the information available to us about Bryn Cross Surgery on 31 August 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 4 April 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bryn Cross Surgery on 4 April 2017. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they found it easy to make an appointment, however not always with their named GP, and 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.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

We saw areas of outstanding practice:

  • The practice worked with the community link worker (CLW). The CLW took referrals for patients who need extra help, but not necessarily medical help.We saw evidence that this had improved the health and well-being of patients accessing this service.

  • The practice operated an apprentice scheme. The scheme has led to employment post scheme in this or other local practices. We saw examples when apprentices had progressed to leadership roles through this scheme.

However there were areas of practice where the provider needs to make improvements:

Importantly the provider should:

  • Ensure actions identified in the infection prevention and control (IPC) audit are completed in a timely manner.

  • Ensure that all patient group directives (PGD) are applied in a consistent manner and are signed by the nurse and authorised by an appropriate clinician.

  • Undertake a legionella risk assessment.

  • Ensure copies of minutes from the team meeting are available to all staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice