We carried out a review of the data available to us about The Mountfield Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about The Mountfield Surgery, you can give feedback on this service.
This practice is rated as Good overall. (Previous inspection 13 August 2015– Good)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
We carried out an announced inspection at Mountfield Surgery on 8 November 2017 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.
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.
All staff were actively engaged in activities to monitor and improve quality and outcomes. For example, a
Staff involved and treated patients with compassion, kindness, dignity and respect.
The practice provided a Monday to Friday morning non appointment based walk in service. People spoke positively about how this allowed them to access care and treatment in a way and at a time that suited them.
There was a strong focus on continuous learning and improvement at all levels of the organisation.
We saw examples of compassionate, inclusive and effective leadership.
We saw two areas of outstanding practice:
One of the practice nurses was an experienced, former district nurse. She coordinated care for elderly, housebound and vulnerable patients and had a proactive programme of scheduled home visits which integrated with the local hospital’s admission avoidance team. A monthly vulnerable patients multidisciplinary team meeting fed into this programme and was also used to review safeguarding concerns.
The practice provided a Monday to Friday morning non appointment based walk in service. Patients spoke positively about how they could access appointments in a way and at a time that suited them.
Clinicians spoke positively about the impact of both of these initiatives on the practice’s avoidable admissions performance (which was in the lowest quartile for the CCG area). For example, CCG wide average performance on avoidable admissions was 8.12 patients per 1,000 compared with the practice’s performance of 2.73 patients per 1,000 (as of November 2017).
The areas where the provider should make improvements are:
Introduce a programme of formal clinical audit, so as to drive a more proactive structured and evidence based approach to improving patient outcomes.
Continue to monitor recent actions taken to widen its patient participation group membership.
Monitor recently introduced improvements to how learning from significant events is shared.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at The Mountfield Surgery on 13 August 2015. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
We saw one area of outstanding practice:
There were areas of practice where the provider should make improvements:
Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.
Chief Inspector of General Practice