The Care Quality Commission
  • Doctor
  • GP practice

Archived: Great Western Surgery

Overall: Good read more about inspection ratings

Farriers Close, Swindon, Wiltshire, SN1 2QU (01793) 421311

Provided and run by:
Carfax Health Enterprise Community Interest Company

Important: The provider of this service changed. See old profile

All Inspections

25 November to 25 November

During a routine inspection

We carried out an announced comprehensive inspection of Great Western Surgery on 25 November 2019, to confirm the practice had carried out their plan to ensure the breaches in regulation identified at a previous inspection. The practice was previously inspected on 20 June 2018 and given an overall rating of Requires Improvement.

Following the inspection on 20 June 2018, the provider sent us an action plan that set out the actions they would take to meet the breached regulations. We then inspected the practice on 26 September 2019. However, we did not apply new ratings to the practice, because we incorrectly undertook a focused rather than comprehensive inspection (a full comprehensive inspection was needed because the practice was rated as Requires Improvement).

This report covers the announced comprehensive inspection carried out on 25 November 2019.

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.

There were three areas where the provider should make improvements. The provider should:

  • Continue efforts to increase the programme coverage of women eligible to be screened for cervical cancer to reach the national target of 80%.
  • Continue to review systems for recording significant events and disseminating subsequent learning to all relevant staff.
  • Continue efforts to increase membership of the patient participation group (PPG).

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

26 September to 26 September

During an inspection looking at part of the service

We carried out an announced inspection of Great Western Surgery on 26 September 2019. The inspection was to confirm 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 20 June 2018 (previous overall rating, Requires Improvement).

We have not applied new ratings to the practice, following this inspection. This is because a comprehensive inspection is needed following 12 months of a practice being rated as requires improvement. This inspection was a focussed inspection to ensure the breaches of regulation had been addressed.

We focused our inspection on the Safe and Well Led domains.

We also looked at specific areas of the Caring and Effective key questions because data findings required further explanation.

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 found that the provider had made improvements since our inspection in 2018, and that these were sufficient to meet regulations for safe and well-led services. 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.

There were three areas where the provider should make improvements. The provider should:

  • Continue efforts to increase the programme coverage of women eligible to be screened for cervical cancer.
  • Continue to review systems for recording significant events and disseminating subsequent learning to all relevant staff.

  • Continue efforts to recruit more members for the patient participation group.

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

20 June to 20 June 2018

During a routine inspection

This practice is rated as Requires Improvement overall. (Previous inspection 8 August 2017 – Requires Improvement).

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection of Great Western Surgery on 8 August 2017. Overall the practice was rated as requires improvement. The comprehensive report for the August 2017 inspection can be found by selecting the ‘all reports’ link for Great Western Surgery on our website at www.cqc.org.uk.

Following the inspection on 8 August 2017, the provider sent us an action plan that set out the actions they would take to meet the breached regulations. We then carried out an announced follow-up comprehensive inspection of Great Western Surgery on 20 June 2018, to confirm 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 8 August 2017. This report covers the announced follow-up comprehensive inspection. We found that although the provider had made improvements since our inspection in 2017, these were not sufficient to meet regulations for safe and well-led services.

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 routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • Great Western Surgery has responded to the needs of its patient group by making routine health appointments at least 15 minutes in duration.
  • Patients on multiple medicines attended the practice for a single review of all their medications needs.
  • There was a proactive approach to understanding the needs of different groups of people and to deliver care in a way that met these needs and promoted equality.
  • Great Western Surgery identified patients at risk of developing diabetes who were not on the diabetes register, and implemented changes that could help to prevent the progression of this health condition.

The areas where the provider must make improvements are:

  • The provider must ensure care and treatment is provided in a safe way to patients.
  • The provider must 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:

  • The provider should continue to make efforts to increase the programme coverage of women eligible to be screened for cervical cancer and other indicators of patient outcomes.
  • The provider should ensure that clinical staff confirm the accuracy of computerised notes by cross-checking these with other records of consultations, and audit this process.

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

8 August 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Great Western Surgery on 8 August 2017. Overall the practice is rated as requires improvement.

The current provider took over the practice in January 2017.

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 provider had defined systems to minimise risks to patient safety. At the time of our inspection, the new provider was implementing their systems within the practice and therefore some processes had not been fully embedded.
  • Systems and processes to action safety alerts such as those from the Medicines and Healthcare products Regulatory Agency did not ensure all staff had received those alerts, and actions taken were not recorded.
  • 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. However, we found there were gaps in staff training and did not show if staff had received those training or required updates, for example, fire training, Mental Capacity Act training and safeguarding training.
  • Not all appropriate recruitment checks had been carried out for staff who had transferred to the current provider from the previous provider.
  • The vaccine fridge had not been calibrated since September 2015 and therefore, the provider could not be assured if the vaccine fridge was operating effectively.
  • Verbal complaints were not recorded and there were no evidence that learning from complaints had been shared with staff.
  • 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.
  • Most patients we spoke with said they found it easy to make an appointment with a GP with urgent appointments available the same day. However, they also commented that they do not always see the same GP which did not contribute to continuity of care
  • Since taking over the practice, the provider had made a number of improvements to the premises and purchased new equipment to ensure these were fit for purpose.
  • 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 practice had a number of policies and procedures to govern activity.
  • 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 care and treatment is provided in a safe way for patients.

  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

  • Ensure specified information is available regarding each person employed.

The areas where the provider should make improvement are:

  • Ensure the temperature of the vaccine fridge is consistently monitored and calibrated in line with the manufacturer’s instructions.

  • Continue to with their programme of reviews for patients with long-term conditions.

  • Ensure patients who have a learning disability have been encouraged to undertake an annual review of their health.

  • Ensure a cycle of re-audits are implemented to monitor patient outcomes.

  • Improve the system for the recording of complaints to ensure verbal complaints are captured and recorded.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice