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The Wilberforce Surgery Good

Reports


Review carried out on 7 October 2021

During a monthly review of our data

We carried out a review of the data available to us about The Wilberforce Surgery on 7 October 2021. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Wilberforce Surgery, you can give feedback on this service.

Review carried out on 6 February 2020

During an annual regulatory review

We reviewed the information available to us about The Wilberforce Surgery on 6 February 2020. 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 27 June 2018

During a routine inspection

This practice is rated as good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at The Wilberforce Surgery on 27 June 2018 as part of our inspection programme. At our previous inspection on 23 August 2017 the overall rating for the practice was requires improvement. The full comprehensive report from the August 2017 inspection can be found by selecting the ‘all reports’ link for The Wilberforce Surgery on our website at . We conducted a further comprehensive follow-up inspection visit on 27 June 2018 and found improvements had been made. The report on the June 2018 inspection can be found by selecting the ‘all reports’ link for The Wilberforce Surgery on our website at

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At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them, and improved their processes.
  • The practice had systems in place to minimise risks to patient safety.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had thoroughly reviewed the effectiveness and appropriateness of the care it provided. They ensured that care and treatment was delivered according to evidence- based guidelines and best practice.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • The practice organised and delivered services to take account of individual and cultural patient 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.
  • Information about services and how to complain was available. Improvements were made to improve the quality of care as a result of complaints and concerns.
  • There was a strong focus on improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Although patient feedback is being sort in other ways the practice should explore ways of introducing and implementing a patient participation group (PPG) to drive improvement.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection carried out on 23 August 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Wilberforce Surgery on 23 August 2017. The overall rating for the practice was requires improvement.

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. However, when things went wrong reviews and investigations into significant events were not thorough enough and lessons learned were not communicated widely enough to support improvement.
  • The practice did not have clearly defined and embedded systems to minimise risks to patient safety, in relation to recall of patients on high risk medicines and the monitoring of vulnerable patients at the practice. For example, the system for completing a review of patient safeguarding cases was not fully implemented and required review and no safeguarding meetings had taken place and the review of vulnerable adults was infrequent.
  • 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.
  • The practice had not completed infection control audits or adopted any action plans for review.

  • The monitoring of the refrigerator temperature checks was not robust and there were gaps in the recording of the refrigerator temperatures.
  • Patient Group Directions (PGDs) had been adopted by the practice to allow nurses to administer medicines in line with legislation. Not all PGDs were they readily available during the inspection.

  • 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.
  • Patients we spoke with said they found it easy to make an appointment with the GP and there was continuity of care, with urgent appointments available the same day.
  • The practice did not have adequate arrangements to respond to emergencies and major incidents. For example, there was no oxygen available at the time of our visit and arrangements for access to a defibrillator had not been established.

  • 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 areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Although patient feedback is being sought in other ways, the practice should develop the patient participation group (PPG) to drive improvement through further suggestions from a patient perspective.

  • Although the provider had a complaints process in place we did not see a transparent system for ensuring patients were aware of what to do in the event they need to make a complaint. For example, there was no information available for patients in the waiting area which explained what to do in the event of a complaint.

  • Review the system that identifies patients who are also carers to help ensure that all patients on the practice list who are carers are offered relevant support if appropriate.
  • Although team meetings take place on an ad-hoc basis the practice should develop a more regular review for staff to have

  • The practice should arrange and hold multi-disciplinary meetings on a frequent basis including meetings with district nurses, social workers and health visitors to monitor vulnerable patients.

  • The practice’s uptake for the cervical screening programme was 69%, which was worse than the local CCG average of 81% and the national average of 81%. The practice should review their process for the recall of patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice