The Care Quality Commission
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Archived: Felton Surgery

Overall: Good read more about inspection ratings

Main Street, Felton, Morpeth, Northumberland, NE65 9PR (01670) 787353

Provided and run by:
Dr Yvonne Clare Lees

All Inspections

02 september 2021

During an inspection looking at part of the service

We carried out an announced inspection at Felton Surgery on the 2 September 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring – Not rated at this inspection

Responsive – Not Rated at this inspection

Well-led – Requires Improvement

Following our previous inspection on 14 February 2017, the practice was rated Good overall and for all key questions.

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

Why we carried out this inspection

This was an announced focused inspection following information of concern we received around how the practice was led.

We inspected the key areas of:

Are services safe?

Are services effective?

Are services well led?

Ratings in the caring and responsive domain are carried forward from the 2017 inspection.

How we carried out the inspection/review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

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 and questionnaires.
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

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 and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Good 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.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.

The way the practice was led and managed promoted the delivery of high-quality, person-centre care. Despite this we identified from feedback received that staff struggled to have their voices and issues heard by the leadership team leaving them feeling undervalued and not listened to

Whilst we found no breaches of regulations, the provider should:

  • Continue to develop and improve the relationship and collaboration between the leadership team and staff
  • Continue to ensure that staff receive their annual appraisal.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

14 February 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Felton Surgery on 14 February 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 an effective system for reporting and recording significant events.

  • Risks to patients and staff were assessed and well managed.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. They had the skills, knowledge and experience to deliver effective care and treatment.

  • The practice used the information collected for the Quality and Outcomes Framework (QOF), to monitor and improve outcomes for patients. The practice’s overall achievement, for 2015/16, was better than the local clinical commissioning group (CCG) and England averages.

  • All staff were actively engaged in monitoring and improving quality and patient outcomes. They were committed to supporting patients to live healthier lives through a targeted and proactive approach to health promotion. This included providing advice and support to patients to help them manage their health and wellbeing.

  • Staff had been proactive in identifying patients with complex needs and multiple long-term conditions, to help ensure they received appropriate care planning and treatment.

  • Services were tailored to meet the needs of individual people and were delivered in a way that provided flexibility, choice and continuity of care.
  • Information about services and how to complain was available and easy to understand.

  • The practice had satisfactory facilities and was well equipped to treat patients and meet their needs.

  • There was a clear leadership structure and staff felt well supported by the management team. The practice had a very effective governance framework, which focussed on delivering safe, good quality care.

  • Staff had a clear vision and strategy for the development of the practice and were committed to providing their patients with good quality care and treatment.

There was also an area of outstanding practice:

  • The practice had been very proactive in taking steps to reduce emergency attendances by patients into hospital, at a time when the local care trust had seen these increase. They had identified a need to reduce emergency attendances and, to help them do this, they had implemented a new appointment system which provided patients with access to same day care. The practice had then audited the improvement they made and this showed that, although the local hospital trust had seen their emergency admissions rate rise by 3.9%, due to winter pressures, the emergency attendances by patients registered with the practice, had reduced by 14% over the same period of time. This included a 20% reduction in emergency attendances by patients aged over 65 years of age, as well as a 50% reduction in emergency attendances by patients aged under five years of age.

However, there were also areas where the provider should make improvements. The provider should:

  • Carry out a recorded risk assessment in relation to any decision made not to obtain a Disclosure and Barring Service check for staff appointed to a particular post.

  • Continue to review the practice’s carers’ register to make sure it accurately reflects the number of patients who are also carers.

  • Display in the patient waiting area information about how to make a complaint.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice