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Eyam Surgery Requires improvement


Inspection carried out on 13/11/2019

During an inspection looking at part of the service

We previously carried out an announced focused inspection at Eyam Surgery on 13 August 2019 as part of our inspection programme. The practice was rated as requires improvement and a warning notice in relation to safe care and treatment was issued. The full focused report on the August 2019 inspection can be found by selecting the ‘all reports’ link for Eyam Surgery on our website at

We carried out an announced focused inspection at Eyam Surgery on 13 November 2019 to ensure that the issues identified in the warning notice had been addressed. This report only covers our findings in relation to the warning notice.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected.
  • information from the provider.

At this inspection, we found that the provider had satisfactorily addressed the issues identified in the warning notice. We found that:

  • Effective oversight, leadership and governance from the senior management team and the dispensary lead GP had been implemented.
  • Processes for the management of controlled drugs including, storage, transport, destruction and record keeping were in line with national guidance and reflected in the dispensary SOPs.
  • Risk assessments covered activities such as transport and delivery of medicines.
  • The process for determining the suitability of medicines to be included in compliance aids for patients ensured the safety of patients and allowed for appropriate risk assessment by the prescriber on an individual patient basis.
  • Suitable waste management streams were available and dispensary staff were aware of the need to segregate waste.
  • There was a detailed process to determine dispensary staff competency. In the absence of a dispenser at the branch site, the GP there would dispense a limited range of medicines.
  • Dispensary meeting minutes detailed regular housekeeping tasks to provide assurance of the safe management of medicine. These tasks included stock expiry date checks, CD checks and waste management.

Details of our findings and the supporting evidence are set out in the evidence table.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care.

Inspection carried out on 13 August 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Eyam Surgery on 13 August 2019 as part of our inspection programme.

We carried out an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

  • Safe
  • Effective
  • Responsive
  • Well-led

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

  • Caring

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 requires improvement overall. The practice was rated as requires improvement for providing safe and well-led services. It was rated as outstanding for responsive and good for effective services. All population groups were rated as being outstanding.

We rated the practice as requires improvement for providing safe services because:

  • The management of systems within the practice dispensary required review with closer monitoring and greater clinical oversight.
  • Some processes had insufficient evidence to provide assurances that they operated safely. This included the tracking of prescription stationery, reviews of the entries on the child safeguarding register, and an effective fail-safe system for cervical cytology screening results.
  • The practice had not considered all areas of potential risk and implemented measures to control these effectively. Where risk assessments had been completed, follow up actions and dates of completion were not consistently documented.
  • Staff files did not always provide sufficient evidence of safe recruitment and immunisation status.

We rated the practice as requires improvement for providing well-led services because:

  • The practice did not have effective systems to identify, manage and mitigate risk. This was particularly evident within the practice dispensary.
  • We found that the oversight of some systems required additional assurances to ensure they were working effectively. For example, we identified issues that required stronger managerial and clinical oversight relating to systems and processes within the practice.

We rated the practice as outstanding for providing responsive services because:

  • The national GP patient survey demonstrated that the practice had performed significantly higher than average in relation to questions relating to appointment availability.
  • The practice had focused on the Accessible Information Standard and had made a number of changes to the environment and ways of working to meet the identified needs of different patient groups.
  • The patient responded to the needs of their patients, for example, by the introduction of a mini-bus service for patients in recognition of the rurality of the area and associated poor transport links with a predominantly older registered patient list.

The high performance in providing outstanding access to care for patients led to all population groups being rated as outstanding.

We rated the practice as good for providing effective services.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way (Please see the specific details on action required at the end of this report).
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. (Please see the specific details on action required at the end of this report).

In addition, the provider should:

  • Provide clear evidence and assurance that all safety alerts are received and acted upon.
  • Consider the approach to how new and revised guidance (including NICE) is reviewed collectively by the clinical team, for example via an established clinical audit programme.
  • Review staff induction programmes to ensure this incorporates all necessary information, training and competencies.

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 16 April 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Eyam Surgery on 16 April 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, well-led, effective, caring and responsive services. It was also good for providing services for older people, people with long term conditions, families, children and young people, working aged people (including those recently retired and students), people whose circumstances make them vulnerable and people with mental health (including people with dementia)

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients and staff were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Patients said they were treated with empathy, compassion, dignity and respect and they were listened to and involved in making decisions about their care and treatment.
  • Information about services and how to complain was available and easy to understand. Complaints were investigated and responded to in a timely and appropriate way.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day. Referrals to secondary care services were made appropriately and in a timely manner in line with local and national guidance and targets.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt passionate and proud of the work they did and the treatment that patients received. Staff were supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider should:

  • Ensure that all staff undertake role specific training in safeguarding vulnerable adults and children.
  • Implement a more robust system for tracking blank prescriptions to minimise risks of misuse or error and to promote robust monitoring of these.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Inspection carried out on 31 July and 14 August 2014

During an inspection looking at part of the service

On this occasion, we did not speak with any people using the service due to the nature of the standards we inspected.

We found that most of the required improvements had been made since our previous inspection in December 2013.

The practice was visibly clean and hygienic, and effective systems were in place to protect patients and staff against the risk of infection.

The practice�s policies and risk assessments had been reviewed to ensure these were up-to-date and accurate. Where risks were highlighted measures had been put in place to minimise the risks.

Regular fire drills were carried out to ensure that people knew how to evacuate the premises safely. Records also showed that all staff had attended recent fire awareness training to ensure they had an adequate knowledge of fire safety, and knew the procedure to follow in the event of a fire.

Robust recruitment procedures were not always followed, to ensure that the required information was available in respect of all staff to ensure they are suitable to carry out the work. We received assurances following the inspection that the recruitment procedures had been strengthened.

Inspection carried out on 4 December 2013

During a routine inspection

We spoke with six patients of Eyam Surgery during our inspection. We did this to help us to understand the outcomes and experiences of patients who used the practice. Patients told us that all of the staff at the practice treated them with respect and the GP�s and nurses were friendly and approachable. Their comments included; �All of the Doctors are very friendly, but thorough� and, �I�ve been supported to access lots of other services through the practice, they�ve been very helpful.�

We found that patients were involved in their care and treatment which was provided in a way intended to ensure their safety and welfare. There was a dispensary service at the practice and we received positive feedback from patients about the service.

Patients were being cared for in a clean, hygienic environment. However we found that patients and staff were not always protected from the risk of infection because appropriate guidance had not been followed.

We found that the provider could not be assured that patients were being cared for, or supported by, suitably qualified, skilled and experienced staff. This was because there were ineffective recruitment and selection procedures in place.

The provider had an effective system to regularly assess and monitor the quality of service that people receive. However we found there were ineffective systems in place to identify, assess and manage the risks to the health, safety and welfare of patients and others.