Background to this inspection
Updated
7 March 2019
Brewood Surgery is registered with CQC as a partnership; they provide a GP service from purpose-built premises in Brewood, Staffordshire. Car parking, (including disabled parking) is available at this practice.
We previously carried out a focused inspection at Brewood Surgery in April 2018. The overall rating for the practice was good with requires improvement for providing safe services. The previous inspection report can be found by selecting the ‘all reports’ link for Brewood Surgery on our website at www.cqc.org.uk.
The practice holds a General Medical Services (GMS) contract with NHS England and is part of the NHS Staffordshire and Surrounds Clinical Commissioning Group (CCG). In addition to the main location at Brewood, the practice also delivers services from two branch locations:
- Wheaton Aston Surgery located at Leabank House, The Cobbles, Wheaton Aston, Stafford, ST19 9NB. Telephone: 01785 841055
- Coven Surgery located at Coven Memorial Hall, Coven, Wolverhampton, WV9 5DL.
We carried out an announced comprehensive inspection at Brewood Surgery, the main practice site and visited the branch surgery at Wheaton Aston, which dispenses medicines to 2,706 patients. The Coven branch was not inspected as part of this visit. The practice area is one of less deprivation when compared with the local average and national average. The practice has more patients aged 50 and over and less patients aged 44 years and younger when compared to the CCG and national average.
At the time of our inspection the practice had 10,600 registered patients
The practice staffing comprises of:
- Four GP partners
- Two salaried GPs
- Three advanced nurse practitioners
- Three practice nurses
- One practice pharmacist
- One assistant healthcare practitioner
- One musculo skeletal therapist
- Two healthcare assistants
- Five dispensary staff
- The management team, which includes the practice manager, assistant practice manager and receptionist manager who oversees the operational delivery of services supported by a team of administrative staff.
Brewood surgery is an approved GP training practice for Registrars (qualified doctors who undertake additional specialist training to gain experience and higher qualification in General Practice and family medicine). At the time of the inspection there were no registrars working at the practice.
The provider offers a range of services and clinics. Further details about the practice can be found on the practice’s website at www.brewoodsurgery.nhs.uk
Updated
7 March 2019
We carried out an announced comprehensive inspection at Brewood Surgery on 6 February 2019 as part of our inspection programme. We also visited the branch at Wheaton Aston as part of this inspection. We did not visit the branch at Coven as part of this inspection.
At the last inspection in April 2018 we rated the practice as requires improvement for providing safe services. This was because:
- There had been no health and safety risk assessment carried out for the premises.
- Non-clinical staff who acted as chaperones had not received a Disclosure and Barring Service (DBS) check and there was no risk assessment in place to demonstrate why such checks were not required.
- Staff were unaware of the practice’s continuity plans.
- We found a breach of regulation in relation to Good Governance: regulation 17 in particular:
- Systems to identify, mitigate and manage potential risks to patients and others in relation to the safe management of medicines was not effective.
- The security of medicines at both the main and branch surgeries was insufficient as there were no formal checks or records only the verbal assurances assurance of the dispenser competing the task.
- Processes did not ensure that all medicines were stored at the correct temperature at the Wheaton Aston branch surgery.
- Staff at the main surgery did not have written guidance or training on the dispensing of medicines.
- The recording of checks on emergency medicines held at the main surgery was not consistent.
- Dispensing records had not been kept for the correct period of time.
- There was no record of disposal for returned medicines at the Wheaton Aston branch surgery or record of disposal of some medicines in controlled drug registers.
- Prescription stationary and medicines were not managed securely at the Wheaton Aston branch surgery.
Our previous reports for this service can be found by selecting the ‘all reports’ link for Brewood Surgery on our website at www.cqc.org.uk.
At this inspection, we found that the provider had satisfactorily addressed these
areas. They had taken the following action in relation to the security issues:
- Both the main site and Wheaton Aston branch dispensaries had locked doors.
- The keys for these doors were securely locked away.
- The practice had active CCTV directed at these doors and all entry points.
- Emergency trolley cupboards on all sites now had tamper evident mechanisms in place
- All medicine fridges were locked on all sites.
- The practice had taken the following actions to imrove the Management of medicines
- All medication was now correctly stored and managed on all sites.
- Standard operating procedures (SOP)s were now in place for both the main and Wheaton Aston branch dispensary.
- The practice had identified responsible individuals and deputies for the dispensaries and procedures. They followed these up with checking procedures.
- The practice had made suitable improvements in the storage and ordering of all medicines.
- Date checking and stock rotation had been implemented at both the main site and Wheaton Aston branch surgery.
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 and
- information from the provider, patients, the public and other organisations.
We have rated this practice as good overall and good for all population groups.
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
Continue to monitor the documents within staff files.
Review the driver risk assessment periodically.
Review the analysis of significant events.
Formalise the clinical reviews for Advanced Nurse Practitioners.
Formalise checks on new procedures.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice