You are here

Reports


Review carried out on 18 October 2019

During an annual regulatory review

We reviewed the information available to us about Everest House Surgery on 18 October 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 21 June 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Everest House Surgery on 5 October 2016. The overall rating for the practice was good. However, we identified breaches of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided safe services. Consequently the practice was rated as requires improvement for providing safe services. The full comprehensive report from the 5 October 2016 inspection can be found by selecting the ‘all reports’ link for Everest House Surgery on our website at www.cqc.org.uk.

After the comprehensive inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to;

  • Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014

- safe care and treatment.

The areas identified as requiring improvement during our inspection in October 2016 were as follows:

  • Ensure that patients prescribed higher risk medicines are monitored and reviewed at the required intervals.
  • Ensure that patients in whom Warfarin should be considered are prescribed it, or have the reasons for why they are not receiving it documented.
  • Ensure that at all times sufficient processes are in place and adhered to for the management and review of results received from secondary care services, for example pathology results.

In addition, we told the provider they should:

  • Ensure that all staff employed are supported by receiving appropriate supervision and appraisal and are completing the essential training relevant to their roles, including infection prevention and control and safeguarding training.
  • Ensure that the infection control lead is appropriately trained and that the infection control protocol is fully specific to the practice.
  • Ensure actions taken to resolve the risks identified by the fire and Legionella risk assessments are recorded and fully completed.
  • Implement a formal and coordinated practice wide approach to ensure the practice’s areas of below average Quality and Outcomes Framework (QOF) performance are improved.
  • Continue to support carers in its patient population by providing annual health reviews.

We carried out an announced focused inspection on 21 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches of regulation that we identified in our previous inspection on 5 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key finding on this focused inspection was that the practice had made improvements since our previous inspection and were now meeting the regulation that had previously been breached.

The practice is now rated as good for providing safe services.

On this inspection we found:

  • A sufficient review and recall process was in place to ensure patients prescribed higher risk medicines were monitored and reviewed at the required intervals.
  • All patients with Atrial Fibrillation were prescribed an anticoagulant medicine or had the reasons they were not receiving it recorded. (Atrial Fibrillation is a heart condition that causes an irregular and often abnormally fast heart rate).
  • A sufficient process was in place and adhered to for the management and review of clinical results received from secondary care services.

Additionally where we previously told the practice they should make improvements our key findings were as follows:

  • Staff had completed infection control and adult and child safeguarding training.
  • The infection control lead was appropriately trained and the infection control protocol was specific to the needs of the practice.
  • Most of the risks identified by the fire and Legionella risk assessments were completed and recorded. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
  • A programme was in place to ensure all staff received an appraisal on an annual basis and this was on schedule for non-clinical staff. We saw that the 16 applicable non-clinical staff had received fully documented appraisals within the past 12 months. The three non-clinical staff employed for less than a year at the time of our inspection were all scheduled to receive their first annual appraisals between August and October 2017.
  • Through implementing a coordinated practice wide approach, the practice had improved its Quality and Outcomes Framework (QOF) performance. (QOF is a system intended to improve the quality of general practice and reward good practice). Figures provided by the practice showed that as of 31 March 2017 the practice had achieved 100% of the total number of points available. This included achieving 100% of the points available for all of the diabetes related indicators. The practice discussed, monitored and reviewed its QOF performance at monthly clinical meetings.
  • The practice had identified inaccuracies in its carers register (those patients on the practice list identified as carers). This was due to recording anomalies. As a result, the practice had undertaken a considerable piece of work including the review of 1,157 patient records in order to ensure the carers register was accurate and fit for purpose. This work was due to be completed by July 2017. Along with this the practice had prioritised identifying carers with the most needs such as those with one or more (multiple) chronic conditions so that they received a carers’ health check as part of their nurse led review. The senior staff we spoke with told us that by that point they were confident the practice would be in a position to start offering carers’ health reviews on a routine basis.

Following our inspection on 21 June 2017 the areas where the provider should make improvements are:

  • Ensure that the infrequently used outlet at the practice is appropriately flushed on a weekly basis and that this is recorded.
  • Continue to identify and support carers in its patient population.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 5 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Everest House Surgery on 5 October 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Some of the systems, processes and practices in place to keep patients safe were insufficient. Processes for the management of patients receiving higher risk medicines and the review of results received from secondary care services required improvement.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • The patients we spoke with or who left comments for us were positive about the standard of care they received and about staff behaviours. They said staff were helpful, friendly, thorough and caring. They told us that their privacy and dignity was respected and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • 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 supported by management. The practice sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

  • Ensure that patients prescribed higher risk medicines are monitored and reviewed at the required intervals.
  • Ensure that patients in whom Warfarin should be considered are prescribed it, or have the reasons for why they are not receiving it documented.
  • Ensure that at all times sufficient processes are in place and adhered to for the management and review of results received from secondary care services, for example pathology results.

The areas where the provider should make improvements are:

  • Ensure that all staff employed are supported by receiving appropriate supervision and appraisal and are completing the essential training relevant to their roles, including infection prevention and control and safeguarding training.
  • Ensure that the infection control lead is appropriately trained and that the infection control protocol is fully specific to the practice.
  • Ensure actions taken to resolve the risks identified by the fire and Legionella risk assessments are recorded and fully completed.
  • Implement a formal and coordinated practice wide approach to ensure the practice’s areas of below average Quality and Outcomes Framework (QOF) performance are improved.
  • Continue to support carers in its patient population by providing annual health reviews.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice