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Archived: The Surgery Good

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Inspection carried out on 14 May 2019

During an inspection looking at part of the service

We decided to undertake an announced focused inspection of this service on 14 May 2019 following our annual review of the information available to us. This inspection looked at the following key questions: Safe, Effective and Well-led.

At the last inspection in August 2018 we rated the practice as good overall, and requires improvement for providing safe services because:

  • There were shortfalls in the systems for monitoring patients on some high-risk medicines.
  • The system to manage uncollected repeat prescriptions was not effective.
  • There were no records to confirm the action taken in response to safety alerts.
  • Some non-clinical staff were unclear about their responsibilities when acting as chaperones.
  • Reception staff had not been provided with training to assist them in identifying a deteriorating or acutely unwell patient.
  • Improvements were needed in the auditing of infection prevention and control.

At this inspection, we found that the provider had satisfactorily addressed these areas.

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.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Complete the outstanding actions identified in the latest infection prevention and control audit.
  • Improve the monitoring and security of blank prescriptions stored in consulting rooms.

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 8 August 2018

During a routine inspection

This practice is rated as Good overall. (Previous rating 01/2015 – Good)

The key questions at this inspection 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 at The Surgery on 8 August 2018 as part of our inspection programme.

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 some systems for appropriate and safe handling of medicines. However, improvements in managing patients taking some high-risk medicines and monitoring uncollected repeat prescriptions were required.
  • 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, although some working age patients reported difficulties accessing care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

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

The areas where the provider should make improvements are:

  • Review and improve the system for managing safety alerts.
  • Improve reception staff training for their role as chaperones and in the management of patients with severe infections.
  • Take action to improve the auditing of infection prevention and control.
  • Implement continuous clinical audit to assess and monitor the quality of care and outcomes for patients.

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

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