The Care Quality Commission
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  • GP practice

Archived: Pewsey Surgery

Overall: Good read more about inspection ratings

The Surgery, High Street, Pewsey, Wiltshire, SN9 5AQ (01672) 569990

Provided and run by:
Pewsey Surgery

All Inspections

10 July 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

When we visited Pewsey Surgery on 3 December 2015 to carry out a comprehensive inspection, we found the practice was not compliant with the regulation relating to good governance. Overall the practice was rated as requires improvement.

We found the practice required improvement for the provision of safe services because management systems to identify, assess and manage environmental risks to patients were weak. For example they did not have a health and safety policy.

We found the practice required improvement for the provision of services responsive to people’s needs because patient feedback about the availability of appointments was not always positive and although the practice had taken action to address this it was too early to tell whether the action identified had made a difference.

Following the inspection the provider sent us an action plan that set out the changes they would make and subsequently supplied information to confirm they had completed the actions.

This focused inspection was undertaken to ensure that the practice was meeting the regulation previously breached. For this reason we have only rated the location for the key questions to which this related. This report should be read in conjunction with the full inspection report of January 2016.

We found the practice had made improvements since our last inspection. The information we received enabled us to find the practice was meeting the regulation that it had previously breached.

Specifically Pewsey Surgery:

  • Had an up-to-date health and safety policy and a range of risk assessments in place to monitor safety of the premises, such as a fire risk assessment.
  • The latest NHS GP survey shows that patient satisfaction with how they could access care and treatment was comparable to the national average.

The areas where the provider should make improvement are:

  • The practice should continue to monitor the ability of its patients being able to access appointments in a timely fashion.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

3 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pewsey Surgery on 3 December 2015.

Overall the practice is rated as requires improvement. Specifically we found the practice good for delivery of effective, caring, and well led services. However, the practice is rated as requiring improvement for delivery of safe and responsive services because some environmental safety issues had not been assessed and patient feedback about obtaining appointments in advance was not always positive. The rating of requires improvement in delivering safe and responsive services affected all population groups.

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

  • There was an open and transparent approach to safety and a 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 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 was available and was easy to understand. This included how to complain and how to provide feedback to the practice.
  • Patients said they were able to make an appointment with a named GP and that 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.

However,

  • A number of environmental risks had not been assessed. For example, a health and safety policy was not in place and risk assessments such as environmental safety had not been undertaken.

  • Patient feedback about access to the surgery by phone and obtaining a convenient booked in advance appointment was not always positive.

We saw one area of outstanding practice:

  • The practice used project funds to enable GPs to undertake one hour care reviews with patients who found it difficult to attend the practice as a home visit. The funding enabled another GP to cover the absence of the GP undertaking the review.

The areas where the provider must make improvement are:

  • To formalise their health and safety policy.

  • To complete appropriate risk assessments to identify, assess and manage risks associated with the practice environment.

  • To implement changes to the appointment system following patient feedback.

The areas where the provider should make improvement are:

  • Completing staff training in accordance with training plans.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

23 October 2013

During a routine inspection

People expressed their views and were involved in making decisions about their care and treatment. The people we spoke with said they were able to make their own informed decisions based on the advice they received from the doctor. They told us they were able to ask questions of the doctor which they felt were always answered satisfactorily. One person said: "they (the GP's) always give me good advice and help me to understand the consequences of my decisions'.

People's needs were assessed and care and treatment was planned and delivered in line with their patient record. The GP we met showed us how a person's medical history and medication was updated on the computer system during the appointment. We saw each set of notes recorded each individual's medical history including any allergies they experienced or medicines they were taking. A full appointment history/chronology of treatment and record of any follow up to previous treatment were well recorded.

All the staff we spoke with showed a clear understanding of what to do and who to contact should they have any concerns about a child or vulnerable adult. We saw the surgery had vulnerable adult and child protection policies and procedures in place. Wiltshire Child Protection and Vulnerable Adults flowcharts were also displayed for easy access.

Applicants who were successful at interview were required to provide evidence of their identity, relevant qualifications, and two references. Identity included a photographic document such as a passport. This was an essential aspect of applying for a computer smart card to give aces to patient records. The person's address was checked generally with copies of utility bills. Certificates of relevant qualifications were provided and placed on file. References were obtained from the candidate's most recent employer and someone who knew them personally. We saw copies of a 'colleague survey' and 'patient survey' which a new GP had provided as evidence of their suitability.

There was evidence that learning from incidents / investigations took place and appropriate changes were implemented. The practice held significant event meetings regularly. We saw the minutes for several of these meetings. These showed us issues were discussed and reviews of specific cases took place. Where actions were needed to be made, these were documented and followed up appropriately.