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Taunton Vale Healthcare Good Also known as Blackbrook Surgery and Victoria Gate Surgery

Inspection Summary

Overall summary & rating


Updated 7 December 2018

This practice is rated as Good overall. (Previous rating 06 2018 – Good overall with requires improvement for safe).

The key question at this inspection are rated as:

Are services safe? - Good

We carried out an announced focused inspection at Taunton Vale Healthcare on 7 November 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in Regulation 12 HSCA (RA) Regulations 2014: Safe care and treatment that we identified. And the areas where the provider should make improvements identified in our previous inspection in June 2018. This report covers our findings in relation to those requirements.

The full comprehensive report on the June 2018 inspection can be found by selecting the ‘all reports’ link for Taunton Vale Healthcare on our website at

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 routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines. They had implemented changes to demonstrate that they had a culture of high-quality sustainable care.
  • There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Improve the completion of the provider’s mandatory training program such as fire safety.
  • Review and continue to monitor cervical smear screening to meet Public Health England screening rates.
  • Risk assess the storing of blank prescription paper in terms of unsupervised cleaner access to clinical rooms.
  • Continue to improve the completion of patient quality indicators in the care and treatment of patients with long-term conditions and those with mental health.

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.

Inspection areas



Updated 7 December 2018

We rated the practice as good for providing a safe service.

At our last inspection, 6 and 7 June 2018 we told the provider they must make improvements to ensure care and treatment was provided in a safe way to patients with regards to infection prevention and control. We issued a requirement notice in respect of these issues and found arrangements had significantly improved when we undertook a follow up inspection of the service on 7 November 2018.

Previously we told the provider they should make improvements:

  • Improve audits to include a practice led full cycle annual audit programme and evidence of changes to practice as a result of clinical audits.
  • Implement regular documented fire drills.
  • Implement actions to improve national targets (QOF) and clinical management of long term conditions.
  • Improve the oversight and recording of mandatory training.

During this inspection we reviewed these areas and the areas on the previous inspection where following inspection, they provided evidence of changes to the systems and processes such as recording of staff immunisation and safety alert management.

Our findings at this inspection:

Safety systems and processes

  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.
  • There was an effective process to identify, understand, monitor and address current and future risks such as infection prevention and control and fire safety. We saw actions as a result of our previous concerns had been addressed or were in the process of being remedied. For example, an infection prevention and control audit and subsequent actions resolved such as the secure storage of clinical waste in a designated area.
  • Since our previous inspection the practice had reviewed and acted in response to a previous fire risk assessment. This included installation of a new fire alarm system. Staff had undertaken a fire evacuation drill and there was a process in place for regular fire drill practice.
  • The practice considered and understood the impact on the quality of care of service changes or developments. Since our previous inspection the practice had installed a new telephone system with more options to allow patients to connect to the appropriate staff. Call waiting times had reduced and the practice had changed staff rotas to cover times of increased patient contact. In addition, they had recruited more administrative staff.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Following our previous visit, the practice had implemented changes to demonstrate that they had a culture of high-quality sustainable care. For example, an annual clinical audit programme and an action plan to improve the management of long term conditions.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses such as the significant variations in quality and outcome framework (QOF) measures. (QOF is a system intended to improve the quality of general practice and reward good practice). We reviewed the action plan and saw measurable actions were being taken such as reviews of patient records, reviewing of coding for diseases and clinical interventions and additional staff recruitment and training.
  • There was clear evidence of an annual audit plan including two-cycle audits. Ongoing action to change practice to improve quality was evident.

Track record on safety

The practice had a good track record on safety.

  • Staff were clear on their roles and accountabilities such as in respect of infection prevention and control and fire safety.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts and following our previous inspection had created an oversight document. They were in the process of reviewing all alerts to ensure appropriate action had been taken.
  • The practice understood the learning needs of staff and provided training via an e-learning system to meet them. Previously we found the practice to have limited oversight of mandatory training completion. The practice now has an oversight document. We found the document was mostly up to date for example, the practice could demonstrate safeguarding training for clinicians was undertaken in a face to face practice meeting but this was not recorded on the oversight document. In addition, there were some gaps in staff completion of some of the providers mandatory training for fire safety, mental capacity and consent.

Please refer to the evidence tables for further information.








Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable