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Review carried out on 13 December 2019

During an annual regulatory review

We reviewed the information available to us about Redlam Surgery on 13 December 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 22 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

The practice was inspected on 16 August 2016. The inspection was a comprehensive inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (HSCA). At that inspection, the practice was rated ‘good’ overall. However, within the key questions safe and well-led, areas were identified as requires improvement, as the practice was not meeting the legislation at that time; Regulation 17 Good governance.

At the inspection in August 2016 we found that systems and processes in place to manage staff training had not been sufficient to ensure all staff had received safeguarding training appropriate for their role.

There were insufficient systems and processes in place to ensure all clinical staff had appropriate medical indemnity cover in place.

The practice supplied an action plan and a range of documents which demonstrated they are now meeting the requirements of Regulation 17 Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection carried out on 16/08/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr A Calow’s Practice on 16 August 2016. Overall the practice is rated as requires improvement.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events. However, this system was not consistently followed.
  • Appropriate learning was implemented following any investigation into significant events.
  • Some risks to patients were assessed and managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • 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. Evidence showed the practice responded quickly to issues raised.

  • Patients mostly said they found it easy to make an appointment with a named GP and 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.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

We saw one area of outstanding practice:

  • The practice had implemented measures to streamline patient access. For example, there was an effective telephone triage system in place and the practice was able to demonstrate to us that 69% of patients accessing the triage system were contacted by telephone by a GP in under 30 minutes, and 91% in under an hour.

The areas where the provider must make improvement are:

  • Ensure all staff, including the safeguarding lead, have received training appropriate to their role in relation to safeguarding children and adults.

  • Ensure appropriate medical indemnity insurance cover is in place for staff.

In addition, the provider should:

  • Newly implemented systems around clinicians’ professional registrations should be embedded into practice’s recruitment and employment process.

  • Implement a consistent approach to documenting significant event analysis.

  • Improve documentation to provide a clear audit trail of information flow within the practice, such as meeting minutes and actions taken on receipt of safety alerts.

  • Monitor the effectiveness of any improvements made via audit and implement the new audit calendar.

  • Continue efforts to establish an active patient participation group.

  • Document timescales for completion of action plans produced as a result of infection prevention and control audits.

  • Documented risk assessments should demonstrate the risk of legionella has been considered.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice