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Inspection carried out on 22 May 2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Stanhope Surgery on 12 April 2018. The practice was rated as requires improvement for providing responsive services, and the overall rating for the practice was good. We carried out an announced focused inspection at Stanhope Surgery on 22 May 2019, to check on the areas previously identified as requiring improvement.

The full comprehensive report on the April 2018 inspection can be found by selecting the ‘all reports’ link for Stanhope Surgery on our website at

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. (Previous rating 04/2018 – Good).

We found that:

  • The practice organised and delivered services to meet patients’ needs.
  • Patients found the appointment system easy to use. Patient comments and information collected by the practice demonstrated that patients were able to access care when they needed it.

At our previous inspection in April 2018 we told the provider they should make improvements in the following areas:

  • Complete the review of the immunisation status of non-clinical staff and ensure a documented process is in place to evidence compliance.
  • Ensure an effective system is in place for monitoring uncollected prescriptions.
  • Continue to encourage patients to attend national screening programmes for breast cancer screening.
  • Ensure all complaints are managed in accordance with recognised guidance and contractual obligations for GPs in England.

At our inspection in May 2019 we found:

  • The provider had established and embedded a staff immunisation policy. All staff members had a record of vaccinations in place, which were in line with national guidance. The practice had a system to ensure this was reviewed on a regular basis.
  • The practice had introduced a protocol for reviewing uncollected prescriptions. From the sample of documents we viewed, we found uncollected prescriptions were being managed appropriately. All uncollected prescriptions were monitored and clinically reviewed by a GP. Patient records were updated accordingly.
  • The practice continued to encourage patients to attend national screening programmes. Information was displayed in the practice and on the practice website. The practice sent text messages out to patients to encourage uptake and a named GP took a lead role in telephoning patients who had failed to attend their screening appointment.
  • The practice had reviewed their complaints policy. From the sample of documents we viewed, we found complaints received by the practice were being managed in accordance with the recognised guidance. The practice responded to all complaints within the set timescales and included information about the Parliamentary and Health Service Ombudsman as standard.

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

  • Continue to monitor and ensure improvements to national patient survey results in all areas below average including access to the practice by telephone and the availability of appointments.
  • Continue to encourage patients to attend national cancer screening programmes.

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

Inspection carried out on <12 April 2018> to <12 April 2018>

During a routine inspection

Inspection carried out on 18 May 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Stanhope Surgery on 18 May 2017. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • There was a system for reporting and recording significant events. Staff were aware of the significant event reporting process. However, there was limited use of the system to record and report safety concerns, incidents and near misses. We were informed that significant events were often managed informally, they were discussed at staff meetings but there was no documented learning from these.
  • Data showed patient outcomes were comparable with the others in most areas but significantly lower for diabetes related indicators. Although some audits had been carried out, they were only in relation to medicines management and were completed following direction from the local clinical commissioning group (CCG).
  • Patients we spoke with said they were treated with compassion, dignity and respect. However the practice scored below average in most areas of the national GP patient survey published in June 2016. For example, 62% of patients said the GP was good at listening to them compared with the clinical commissioning group (CCG) average of 88% and the national average of 89%.
  • The practice had adequate arrangements to respond to emergencies and major incidents. However, a copy of the business continuity plan was not kept off site by the GP partners or other staff members so could not be used for reference if the building was not accessible.
  • Risks to patients were assessed and well managed.
  • 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.
  • Staff had received inductions, annual performance reviews and attended staff meetings and training opportunities.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had identified 203 patients as carers, which equated to approximately 3% of the practice list.
  • The practice employed a clinical pharmacist as part of a pilot programme to test the role of clinical pharmacy in general practice. They submitted a bid to the local CCG and were approved for funding to take part in the pilot. They recruited a pharmacist and supported their training to become an independent prescriber.

The area where the provider must make improvements are:

  • Identify, document and investigate safety incidents thoroughly and ensure that patients affected receive support and a verbal and written apology and ensure learning from incidents are documented, shared and trends are considered.

In addition the provider should:

  • Continue to make improvements to the care and monitoring of patients with diabetes (long-term conditions).
  • Ensure a process for continuous clinical improvement is introduced. For example, practice specific clinical audit and re-audit to improve patient outcomes.
  • Continue to encourage patients to attend national screening programmes for bowel and breast cancer screening.
  • Continue to monitor and ensure improvements to national patient survey results in all areas including access to the practice by telephone and availability of appointments.
  • Keep a copy of the business continuity plan offsite for use if the building is inaccessible.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice