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Reports


Inspection carried out on 8 February 2018

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

We carried out an announced comprehensive inspection at South Saxon House Surgery on 27 September 2017. The overall rating for the practice was good. The practice was also rated good for the effective, caring, responsive and well-led domains and all of the population groups. It was however rated as requires improvement for the safe domain. The full comprehensive report on the September 2017 inspection can be found by selecting the ‘all reports’ link for South Saxon House Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 8 February 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 27 September 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

At our inspection of 27 September 2017, we found that:

  • The system for recording and monitoring Medicines & Healthcare products

    Regulatory Agency

     (MHRA) alerts did not ensure that clinical action was always taken.

  • Not all external storage bins containing clinical waste were kept locked at all times.

  • Batch numbers, expiry dates and amounts used were not always recorded when local anaesthetic was used during minor surgical procedures.

At this inspection our key findings were as follows:

  • The systems for recording MHRA and other alerts ensured that the alerts and actions were recorded and acted upon.

  • All external clinical waste storage bins were locked at all times.

  • Batch numbers, expiry dates and amounts used were always recorded when local anaesthetic was used during minor surgical procedures.

Additionally we saw that:

  • The system for tracking and auditing histology specimens ensured that results were received and acted upon appropriately.

  • Alerts denoting a child at risk were also placed on family and other household members’ computer records as appropriate.

  • The practice had discussed areas in the GP national survey where results were below the local and national averages and were considering ways of addressing them.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 27 September 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at South Saxon House Surgery on 27 September 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 clearly defined and embedded systems to minimise risks to patient safety although there were areas related to actioning alerts, clinical waste management and medicines management that required review.
  • 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, the friends and family test, discussions with patients and opinions from comment cards 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 in response to patient feedback.
  • Patients we spoke with said they found it easy to make an appointment with a 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.

The areas where the provider must make improvement are:

  • Ensure that all clinical (MHRA) alerts are acted upon and the actions recorded.

  • Ensure that all storage bins containing clinical waste are kept locked at all times.

  • Ensure that batch numbers, expiry dates and amounts used are always recorded when using injectable local anaesthetic.

The areas where the provider should make improvement are:

  • Keep the revised system for audit trailing minor surgery histology specimens under regular review.

  • Ensure that alerts for children at risk which are placed on the practice computer are also placed on family or other household members’ records, as appropriate.

  • Monitor national GP survey responses and consider ways of improving responses on any that are below local and national averages.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice