We carried out a review of the data available to us about Friary House Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Friary House Surgery, you can give feedback on this service.
This practice is rated as Good overall. (Previous inspection 30 November 2016 – Good)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
We carried out an announced comprehensive inspection at Friary House Surgery on 5 December 2017 as part of our planned inspection programme.
At this inspection we found:
Chief Inspector of General Practice
We carried out a comprehensive inspection of Friary House Surgery on 27 April 2016; overall the practice was rated as requires improvement. The practice had been rated as good for providing caring and effective services and requires improvement for providing safe, responsive and well-led services. This was because the practice had not embedded systems that kept patients safe and had not ensured effective governance arrangements monitored and improved quality of services provided to patients.
We undertook a focused follow up inspection on 30 November 2016 to look at the areas identified for improvement. We found the practice had taken appropriate action to ensure patients were kept safe and were listened to. The practice had embedded systems that monitored and improved quality of services provided to patients. The safe, responsive and well-led domains are now rated as good, with the overall practice being rated as good for all domains and population groups.
This report covers our findings in regard of the requirements and should be read in conjunction with the report published in October 2016. This can be done by selecting the 'all reports' link for Friary House Surgery on our website at www.cqc.org.uk .
At this inspection our key findings were:
The areas where the provider should make improvement are:
Ensure patient access to services and appointments are reviewed and improved to support improvements in patient satisfaction.
Improve patient engagement such as through an active patient participation group (PPG).
Chief Inspector of General Practice
We carried out an announced comprehensive follow up inspection at The Friary House Surgery on 27 April 2016. Overall the practice is rated as requires improvement.
We found that improvements had been made since the previous inspection of June 2015 when the practice had been rated as inadequate and was placed into Special Measures.
Our key findings across all the areas we inspected were as follows:
The practice had put in place new policies and procedures to make improvements following the last inspection; some of the new arrangements were at an early stage and had not been fully embedded into the practice.
The areas where the provider must make improvements are:
Ensure that all staff undertaking chaperone duties have a DBS check or a risk assessment to ensure patient safety is fully considered.
Ensure more effective governance arrangements are put in place to monitor and improve the quality of services provided to patients.
Ensure systems are in place to monitor patients prescribed with high risk medicines prior to re-prescribing. Continue to monitor fridge temperatures to ensure medicines are stored safely and review staff awareness of medicines protocols in regard of vaccine storage.
Ensure patient access to services and appointments are reviewed and improved to support improvements in patient satisfaction.
In addition the provider should:
Review processes for clinical audits or quality improvement initiatives including staff awareness of infection control audits.
Review the management of verbal complaints as part of the overall complaints management process.
Review systems to identify record and support patients who are also carers.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Friary House Surgery on 4 June 2015. Overall the practice is rated as inadequate.
Specifically, we found the practice to require improvement for providing safe and caring services. We found the practice to be inadequate for providing effective, responsive and well led care.
Our key findings across all the areas we inspected were as follows:
Action the provider must take to improve:
On the basis of the ratings given to the practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again within six months to consider whether sufficient improvements have been made. If insufficient improvements have been made, such that there remains a rating of inadequate for any population group, key question, or overall, we will take action in line with our enforcement procedures.
Chief Inspector of General Practice
During our inspection of 23 September 2014 we found that significant improvements had been made and that the practice had achieved compliance regarding safeguarding.
Safeguarding training had been provided to all staff at the practice within the last twelve months. Relevant contact details and easy to follow guidance regarding safeguarding procedures were on display in staff areas. Safeguarding had been included as a regular agenda item at team meetings.
We spoke with four patients. All of them told us that they felt safe at the practice and that they had confidence in their GP and the practice staff.
The practice had responded to the findings of the previous CQC inspection report and had taken action to successfully achieve compliance.
We were told that staff treated people with respect and dignity. However information and facilities for some patients with disabilities and non English speakers could be improved.
None of the staff knew the correct local safeguarding procedures although all were confident they would find out and take appropriate action. Staff had attended safeguarding children training but not all had attended safeguarding adult training. The policies for safeguarding adults and children contained incorrect contact numbers.
Patients told us that they always felt safe in the care of the staff. There were appropriate arrangements in place which ensured that staff kept their knowledge and skills up to date. Staff spoke about the supportive environment and confirmed that they had access to adequate training.
The practice was organised and well led. There were effective systems in place to monitor the quality of the service provided and patients felt able to give feedback about the service they received.