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Inspection carried out on 23 May 2017

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Elborough Street Surgery on 17 November 2016. The overall rating for the practice was good; however the safe domain was rated as requires improvement as:

  • The practice did not have an automatic external defibrillator (AED) available on the premises for use in medical emergencies and no formal risk assessment in place to mitigate the risk to patients of not having one.

We also asked the practice to:

  • Review how patients with caring responsibilities were identified and recorded on the clinical system to ensure information, advice and support was made available to them.
  • Review the requirements for, and stocks of, emergency medicines in the practice to ensure these were in line with guidance and meeting the needs of patients.

The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Elborough Street Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 23 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 17 November 2016. This report covers our findings in relation to those requirements and also any additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

  • The practice had installed an AED in the practice and all staff had been trained to use it.
  • The practice had reviewed and had put in place systems to improve how carers were identified. For example, the practice spoke to patient opportunistically, including those on the practice register of patients at risk of admission to hospital, to ask them if they had caring responsibilities. The practice also reviewed their computer system to make sure that patients were correctly ‘coded’ after being identified as having caring responsibilities (coding allows the computer system to be searched to find groups of patients with common interests or conditions or patients with specific needs such as carers). Carers are now included in the practice quarterly care planning process, where patient needs are reviewed and staff updated on information and support available. However the practice were unable to demonstrate the impact of the work or the increase in the numbers of carers identified.
  • The practice had reviewed their emergency medicines and had updated stocks to include recommended medicines that were not present at our last inspection; Aspirin (used in the treatment of suspected myocardial infarction, a heart attack) and Diazepam (used in the treatment of epileptic seizures).

The areas where the provider should make improvement are:

  • Review how patients with caring responsibilities were identified and recorded on the clinical system to ensure information, advice and support was made available to them.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 17 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice


We carried out an announced comprehensive inspection at Elborough Street Surgery on 17 November 2016. Overall the practice is rated as good.

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

  • Risks to patients were assessed and well managed, with the exception of the practice not having an automatic external defibrillator (AED) available on the premises for use in medical emergencies and no formal risk assessment in place to mitigate the risk to patients of not having one.
  • There were emergency medicines not in the practice stock that we would normally expect to see and no risk assessment mitigating their absence.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect 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 proactively 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 improvement are:

  • Install an Automatic External Defibrillator (AED) for use in medical emergencies or complete a risk assessment which mitigates the risks of not having one.

The areas where the provider should make improvement are:

  • Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

  • Review the requirements for and stocks of emergency medicines in the practice to ensure these are in line with guidance and meet the needs of patients.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice