You are here

Inspection Summary


Overall summary & rating

Good

Updated 24 January 2017

Letter from the Chief Inspector of General Practice

We carried out an announced focussed inspection at The Southgate Surgery on Wednesday 14 December 2016. We found the practice to be good for providing an effective service and is rated as good overall.

We had previously conducted an announced comprehensive inspection of the practice on 21 October 2015. As a result of our findings during the visit, the practice was rated as good for being safe, caring, responsive and well led and requires improvement for being effective, which resulted in a rating of good overall. We found that the provider had breached one regulation of the Health and Social Care Act 2008; in relation to Regulation 18(2)(a), a number of staff had not received a regular appraisal of their performance in their role from an appropriately skilled and experienced person. Learning and development needs had not been fully identified.

The practice wrote to us to tell us what they would do to make improvements and meet the legal requirement. We undertook this focussed inspection to check that the practice had followed their plan, and to confirm that they had met the legal requirement identified.

This report only covers our findings in relation to those areas where requirements had not been met. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Southgate Surgery on our website at http://www.cqc.org.uk/location/ 1-2794187929.

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

  • Arrangements for staff appraisal were in place. All staff working at the practice had received a recent appraisal that had identified learning and development needs.

  • A training matrix had been developed to ensure that all practice staff kept up to date with all training.

  • The lead for infection control had received appropriate training commensurate to the role of lead.

  • A review of arrangements for the control of substances hazardous to health (COSHH) had been undertaken including a risk assessment.

  • The practice were continuing to develop its strategy and plans around the enhancement of services and facilities to support the growing patient population.

  • Arrangements were in place to identify, record and manage risks and actions to mitigate risks were being recorded.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 24 December 2015

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events.
  • Lessons were shared to make sure action was taken to improve safety in the practice.
  • When there were unintended or unexpected safety incidents, people received reasonable support, truthful information, a verbal and written apology and were told about any actions to improve processes to prevent the same thing happening again.
  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.
  • Risks to patients were assessed and well managed.

Effective

Good

Updated 24 January 2017

The practice is rated as good for providing effective services.

  • The practice had reviewed its staff appraisal system. All staff working at the practice had received a recent appraisal that had identified learning and development needs.

Caring

Good

Updated 24 December 2015

The practice is rated as good for providing caring services.

  • Data showed that patients rated the practice higher than others for several aspects of care.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We also saw that staff treated patients with kindness and respect, and maintained confidentiality.

Responsive

Good

Updated 24 December 2015

The practice is rated as good for providing responsive services.

  • It reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group (CCG) to secure improvements to services where these were identified. For example, the practice staff regularly attended meetings with the local CCG to discuss performance across the locality and issues affecting the local population so that services could be targeted appropriately. For example, recent discussions about the development of local initiatives to support patients from abroad who have been used to accessing different healthcare delivery models.
  • Patients said they found it easy 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.
  • Information about how to complain was available and easy to understand and evidence showed that the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 24 December 2015

The practice is rated as good for being well-led.

  • It had a clear vision to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to this.
  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.
Checks on specific services

People with long term conditions

Good

Updated 24 January 2017

The practice is rated as good for the care of people with long term conditions. As the practice was found to be providing good services overall, this affected the rating for the population groups we inspect against.

Families, children and young people

Good

Updated 24 January 2017

The practice is rated as good for the care of families, children and young people. As the practice was found to be providing good services overall, this affected the rating for the population groups we inspect against.

Older people

Good

Updated 24 January 2017

The practice is rated as good for the care of older people. As the practice was found to be providing good services overall, this affected the rating for the population groups we inspect against.

Working age people (including those recently retired and students)

Good

Updated 24 January 2017

The practice is rated as good for the care of working age people (including those recently retired and students). As the practice was found to be providing good services overall, this affected the rating for the population groups we inspect against.

People experiencing poor mental health (including people with dementia)

Good

Updated 24 January 2017

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia). As the practice was found to be providing good services overall, this affected the rating for the population groups we inspect against.

People whose circumstances may make them vulnerable

Good

Updated 24 January 2017

The practice is rated as good for the care of people whose circumstances may make them vulnerable. As the practice was found to be providing good services overall, this affected the rating for the population groups we inspect against.