We carried out a review of the data available to us about Southbourne 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 Southbourne Surgery, you can give feedback on this service.
We carried out an announced comprehensive inspection at Southbourne Surgery on 22 March 2016. Overall the practice was rated as good for providing effective, caring and responsive services; and was rated as requires improvement for providing safe and well-led services. As a result, the practice was given an overall rating of requires improvement. Following the inspection we issued two requirement notices. A notice was issued due to a breach of Regulation 12 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to safe care and treatment; and a notice was issued due to a breach of Regulation 17 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to good governance.
There were several areas of risk identified at Southbourne Surgery. Within our last inspection report we said the provider must ensure that:
The full comprehensive report on the 22 March 2016 inspection can be found by selecting the ‘all reports’ link for Southbourne Surgery on our website at www.cqc.org.uk.
We undertook a focused inspection of the practice on 28 March 2017. The inspection was to confirm that the practice had implemented its action plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 22 March 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Our key findings across all the areas we inspected during this inspection, were as follows:
Following this inspection the practice was rated as good overall across all domains.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
Following an announced comprehensive inspection of Southbourne Surgery in May 2015 the practice was given an overall rating of requires improvement.
The practice was rated as inadequate for providing safe, requires improvement for well-led services and good for providing caring, effective and responsive services. In addition, all six population groups were rated as requires improvement. At our inspection we identified concerns relating to building and equipment safety checks, the provision of emergency equipment, recruitment and appraisal of staff. We also had concerns in respect of the recording, analysis, and sharing of learning from significant events.
After the comprehensive inspection, the practice wrote and provided an action plan to tell us what they would do in respect of our inspection report findings and to meet legal requirements. The practice told us that they would have completed their action plan by 30 October 2015. We undertook a further comprehensive inspection on 22 March 2016 to check that they had followed their plan and to confirm that they now met legal requirements. Overall the practice is rated as requires improvement following this inspection.
Our previous inspection in May 2015 found the following areas where the practice must improve:
Ensure that policies and procedures relating to health and safety are updated and implemented with risks being identified, documented and managed, including managing risks from fire.
Ensure that Patient Group Directions are implemented; ensure that emergency medicines are available and that procedures are in place to check emergency medicines are in date for use and that there is a record of these checks available.
Ensure that a chaperoning policy is in place, and that staff are provided with effective training and guidance on chaperoning procedures to safeguard patients.
Ensure that policies and procedures for infection control are implemented and audited.
Ensure that all equipment used has appropriate maintenance checks and is suitable for use.
Ensure that staff are trained to support patients in the use of equipment such as the stair lift.
In addition the provider should:
Ensure that practice meetings are documented and include analysis of significant events and any lessons learned.
Equipment such as couches should be identified and replaced when no longer suitable for use
Provide staff with documented policies and procedures regarding consent to care and treatment.
Provide updated information for patients about how to make a complaint
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk
Our key findings across the areas we inspected for this inspection were as follows:
Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
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, however the practice could not provide evidence of all appropriate training for example safeguarding training.
The arrangements for managing medicines, including emergency medicines and administering vaccines, in the practice kept patients safe.
There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events, however learning was not always shared widely enough in the practice to support improvement.
Risks to patients were assessed and well managed.
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 a number of policies and procedures to govern activity, including some new polices such as a chaperone policy, but there was no system in place to ensure that they were up to date and some were overdue a review.
There was a clear leadership structure and staff felt supported by management. The practice acted on feedback from staff and patients.
The provider was aware of and complied with the requirements of the Duty of Candour.
The areas where the provider must make improvement are:
Ensure that a robust system is put in place to ensure that all policies and procedures are updated, implemented and that all staff are aware of how to access them.
Investigate ways to improve communication within the practice. Ensure that practice meetings, including GP meetings, are documented and the minutes are available to appropriate staff within a reasonable time and that learning from significant events is shared appropriately to support improvement.
Ensure that policies and procedures for infection control are fully implemented including a robust system for stock checks and appropriate use of sharps safes.
Ensure that there is a Disclosure and Barring Service check or risk assessment to determine whether a check is required is in place for all staff.
Ensure that all staff are trained to appropriate level in adult and child safeguarding.
Ensure that a system of annual staff appraisals is implemented.
Ensure that all equipment used has appropriate maintenance checks and is suitable for use, including the stair lifts.
Ensure that staff are trained and are confident to support patients in the use of equipment such as the stair lift.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Southbourne Surgery on 21 May 2015. Overall the practice is rated as requires improvement.
Specifically, we found the practice inadequate for providing safe services and required improvement for providing well-led services. The practice required improvement for providing services for the population groups of older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students, people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia). The practice was rated good for providing effective, caring and responsive services.
Our key findings were as follows:
The areas where the provider must make improvements are:
In addition the provider should:
Chief Inspector of General Practice