• Doctor
  • GP practice

The Shrubbery Surgery

Overall: Requires improvement read more about inspection ratings

The Shrubbery, 65a Perry Street, Northfleet, Gravesend, Kent, DA11 8RD (01474) 356661

Provided and run by:
The Shrubbery Surgery

All Inspections

01 November 2022

During an inspection looking at part of the service

We carried out an announced inspection at The Shrubbery Surgery on 01 November 2022.

Overall, the practice is rated as Requires Improvement.

Safe – Requires Improvement

Effective – Requires Improvement

Responsive - Good

Well-led - Good

Why we carried out this inspectionThis was an announced comprehensive inspection to provide the practice with an up to date rating. At our previous inspection on 06 August 2015, the practice was rated Good overall.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Shrubbery Surgery on our website at www.cqc.org.uk

How we carried out the inspectionThroughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing,
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider,
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider,
  • A short site visit.

Our findings

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

We rated the practice as Requires Improvement for providing Safe and Effective services.

We found that:

  • Improvement was required in the monitoring of vaccine fridges.
  • Our clinical record searches found improvement was required in relation to the safe management and monitoring of long-term conditions and high-risk medicines.

We rated the practice Good for providing well-led services.

We found that:

  • The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of person-centre care.
  • The practice exhibited an open culture, the leadership team were freely accessible to staff and staff felt included and listened to.

We found one breach of regulations. The provider must:

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

The provider should:

  • Ensure that their newly improved and implemented procedures for patient group directives, high-risk medicines and long-term condition management are embedded.
  • Continue to follow and embed revised procedures for the monitoring of oxygen and other emergency equipment at The Shrubbery site.
  • Continue with their action plan to ensure that all historical safety alerts were being routinely reviewed.
  • Follow up the proposal to appoint a Freedom to Speak Up Guardian.
  • Continue with the plans to restart the Patient Participation Group (PPG).

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

13 May 2015

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at The Shrubbery Surgery on the 13 May 2015. The provider operated another branch practice within the same area that was not part of this inspection. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe and well-led services.

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

  • Risks to patients were identified, assessed and monitored, including those associated with legionella.
  • A risk management system had been implemented to help monitor safety within the practice.
  • Recruitment checks for staff joining the practice were undertaken and the appropriate information was kept on staff files.
  • Clinical audits had been undertaken and the findings shared with staff, and a system of planned audits and re-audits had been implemented to help improve outcomes for patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

7 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

A comprehensive inspection was undertaken at The Shrubbery Surgery on the 7 October 2014. The provider operated a second branch practice within the same area, that was not part of this inspection.

We found that overall, the practice offered a good level of service to all of the patient population groups who received services from the practice. Our key findings included:-

  • patients felt they were treated with respect and dignity
  • that staff were helpful, kind and considerate to their needs
  • that their privacy and confidentiality was maintained.

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

Importantly, the provider must:

  • Have processes in place for staff to follow to carry out regular checks to reduce the risk of legionella.
  • Follow the practice recruitment policy to ensure all checks are in place when staff are employed.
  • Review systems and processes for monitoring the quality and safety of the services provided including the completion of risk assessments following infection control audits where risks are identified and take steps to ensure all / other risks are assessed, monitored and managed appropriately.
  • Follow processes for undertaking regular full clinical audit cycles to improve patient care.

In addition the provider should:

  • Risk assess how emergency medicine stocks are stored.
  • Risk assess the systems used for the security and control of blank prescription forms kept in computer printers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice