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Inspection carried out on 14 December 2016

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 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 carried out on 21 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Southgate Surgery on 21 October 2015. Overall the practice is rated as Good.

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

  • 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 the skills, knowledge and experience to deliver effective care and treatment.

  • Staff learning and development needs were not identified through an appraisal system.

  • 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.

  • 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.

  • The practice had proactively sought feedback from patients and had an active patient participation group.

  • Although, a vision was in place, the practice did not have a robust strategy and set of business plans that reflected the vision and mission of the practice going forward.

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

Importantly the provider must:

  • Ensure that an appraisal system is in place for all staff at the practice.

Importantly the provider should:

  • Ensure there is an up to date risk assessment in place to monitor the control of substances hazardous to health.
  • Ensure that there is a training matrix in place for all staff to ensure that training is kept up to date.
  • Ensure the lead for infection control had appropriate training commensurate to the role of lead.
  • Develop a robust business strategy and supporting business plans that reflect the practice’s vision and values and support appraisal.
  • Ensure there are robust arrangements for identifying, recording and managing risks, issues and implement mitigating actions.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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.