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Inspection carried out on 10 Apr to 10 Apr 2018

During a routine inspection

This practice is rated as Good overall. (Previous inspection December 2014 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at The Culverhay Surgery on 10 April 2018 as part of our inspection programme.

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.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • Feedback from patients and the patient participation group was positive regarding the quality of care experienced at the practice.
  • The practice had undertaken an Equality Impact Assessment (EIA) on its recruitment processes to ensure the values of equality and diversity were maintained when undertaking recruitment.
  • The premises had undergone significant refurbishment which had improved the facilities and created space for additional consulting rooms.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

We found an area of Outstanding Practice:

  • GPs at the practice undertook bi-annual joint visits with a local Consultant in Psychiatry for old age people where each person living in a care or nursing home was reviewed.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

  • Formalise processes in the dispensary so that medicines check, including controlled drugs and near misses are recorded.
  • Review access arrangements so that only authorised staff have access to the controlled drugs keys.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection carried out on 9 December 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

The Culverhay Surgery in Wotton-Under-Edge was inspected on the 9 December 2014. This was a comprehensive inspection.

The Culverhay Surgery in Wotton-Under-Edge Gloucestershire, GL12 7LS provides primary medical services to people living in the town of Wotton-Under-Edge and the surrounding villages. The practice also has two branch surgeries. One in Wickwar, held in the Community Centre, Avon Crescent on Monday afternoons from 12 noon, and a second in Hawkesbury Upton at the Bethesda Chapel, Park Street on Wednesdays from 12:30pm. We did not visit these branches as part of our inspection.

At the time of our inspection there were approximately 6,300 patients registered at the Culverhay Surgery. This is a dispensing practice and provides a dispensing service to approximately 40% of the practice population. A dispensing practice is where GPs are able to prescribe and dispense medicines directly to patients who live in a rural setting which is a set distance from a pharmacy.

Patients using the practice also have access to community staff including district nurses, health visitors, and midwives.

The practice has opted out of providing out of hours services to their own patients and refers them at evenings and weekends, when the practice is closed, an Out of Hours service delivered by another provider.

We rated this practice as Good.

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from incidents were taken advantage of.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group.

  • Patients had a variety of ways to make appointments and found the practice to be flexible in meeting their needs. We were told patients could always get an appointment.

  • The practice had good facilities and was well equipped to treat patients and meet their needs. Patients told us the practice was clean and safe.

  • The practice had a clear vision which had quality and safety as its first priority and high standards were promoted and owned by all practice staff with evidence of team working across all roles.

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

Action the provider SHOULD take to improve:

  • All clinical staff should receive training in the Mental Capacity Act (2005). The MCA is a legal framework which supports patients who needs assistance to make important decisions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

CQC Insight

These reports bring together existing national data from a range of indicators that allow us to identify and monitor changes in the quality of care outside of our inspections. The data within the reports do not constitute a judgement on performance, but inform our inspection teams. Our judgements on quality and safety continue to come only after inspection and we will not make judgements on data alone. The evidence tables published alongside our inspection reports from April 2018 onwards replace the information contained in these files.