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Reports


Review carried out on 22 November 2019

During an annual regulatory review

We reviewed the information available to us about Sedlescombe House on 22 November 2019. 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 02 November 2018

During an inspection to make sure that the improvements required had been made

This practice is rated as Good overall. (Previous rating 02 May 2018 – Overall Good – requires improvement in safe)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Not inspected on this occasion

Are services caring? – Not inspected on this occasion

Are services responsive? – Not inspected on this occasion

Are services well-led? - Not inspected on this occasion

We carried out an announced comprehensive inspection at Sedlescombe House on 02 May 2018. The overall rating for the practice was good. The practice was also rated good for the effective, caring, responsive and well-led domains and all the population groups. It was however rated as requires improvement for providing safe services. The full comprehensive report on the May 2018 inspection can be found by selecting the ‘all reports’ link for Sedlescombe House on our website at: www.cqc.org.uk

After the inspection in May 2018 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

At this inspection our key findings were:

There was an effective system for managing and actioning safety alerts appropriately. Actions in relation to safety alerts were recorded.

Prescriptions were tracked to specific printers and their numbers recorded.

Checks on emergency equipment were recorded.

Appropriate checks were carried out and recorded when recruiting locum staff.

Systems and protocols for the monitoring of high risk medicines were followed. However a potential weakness in the new monitoring system for a medicine, whose management was shared with the hospital, was identified.

Additionally, we saw that the practice had:

Provided awareness training for all staff on the ‘red flag’ sepsis symptoms that might be reported by patients and how to respond.

Reviewed and improved systems for ensuring sharps boxes were disposed of within their expiry date.

Reviewed and improved systems for identifying and recording carers.

The areas where the provider should make improvements are:

Continue to review, improve and audit the new system for monitoring high risk medicines.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection carried out on 02 May 2018

During a routine inspection

This practice is rated as Good overall. (No previous inspection under this legal entity)

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? - Good

We carried out an announced comprehensive inspection at Sedlescombe House Surgery on 02 May 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had 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.
  • However, although there were systems and protocols for receiving, reviewing and actioning safety alerts the actions were not always recorded.
  • The practice had systems for the handling of medicines, however prescriptions were not tracked to specific printers and checks on oxygen and the defibrillator were not recorded.
  • There was a protocol for monitoring patients on high risk medicines although in the case of one medicine this had not been as strictly adhered to.
  • Appropriate staff checks were carried out at recruitment for permanent staff although references were not always taken up and recorded when employing locum staff.
  • 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 an active patient participation group in place who felt listened to and valued.
  • Staff were positive about working in the practice and felt valued and supported in their roles.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

Provide awareness training for all staff on the ‘red flag’ sepsis symptoms that might be reported by patients and how to respond.

Review and improve systems for ensuring sharps boxes are disposed of within their expiry date

Review and improve systems for identifying and recording carers.

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