We carried out a review of the data available to us about High Street 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 High Street Surgery, you can give feedback on this service.
We carried out an announced comprehensive inspection at High Street Surgery on 28 February 2017. The overall rating for the practice was requires improvement. The full comprehensive report on the February 2017 inspection can be found by selecting the ‘all reports’ link for High Street Surgery on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 14 November 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 28 February 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is now rated as good.
Our key findings were as follows:
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at the High Street Surgery on 26 August 2015. The overall rating for the practice was requires improvement. The full comprehensive report on the August 2015 inspection can be found by selecting the ‘all reports’ link for High Street Surgery on our website at www.cqc.org.uk.
After the inspection in August 2015 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.
The inspection carried out on 28 February 2017 found that the practice had responded to the concerns raised at the August 2015 inspection and had implemented their action plan in order to comply with the requirement notices issued. However, we found other breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating for the practice remains requires improvement.
Our key findings were as follows:
The practice’s systems, processes and practices did not always keep patients safe. Nor were risks to patients assessed and managed in an effective and timely manner.
The practice did not have adequate arrangements to respond to emergencies at the Whitfield Surgery.
The arrangements for managing medicines, including emergency medicines and vaccines, in the practice did not always minimise risks to patient safety.
There was information in the practice leaflet for new patients directing complainants to the practice manager. However, there were no complaints information posters displayed, information published on their website or a complaints leaflet made available.
The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements
However, there were also areas of practice where the provider needs to make improvements.
Importantly, the provider must:
Ensure that the practice has regard to The Health and Social Care Act 2008, Code of practice on the prevention and control of infections and related guidance.
Revise medicines management processes to help ensure there is a system to monitor blank prescription forms and pads and track them through the practice. Ensure that vaccines are stored appropriately. Ensure staff read, understand and sign standard operating procedures relevant to their role and errors and near misses are consistently reported and discussions take place for staff to learn lessons to reduce further risk.
Ensure appropriate recruitment checks are undertaken prior to the employment of all staff, including directly employed locum GPs. Ensure all staff are up to date with mandatory training.
Revise risk management and governance documents to ensure that all risks to patients, staff and visitors are identified and managing in an effective and timely manner. For example, fire risk assessments and evacuation, infection prevention and control, legionella management and responding to medical emergencies.
In addition the provider should:
Review how information is shared with patients who may wish to make a compliant.
Review how patients who use wheel chairs access the practice.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at High Street Surgery on 26 August 2015. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, when things went wrong, reviews and investigations were not thoroughand the practice was unable to demonstrate that lessons learned werecommunicated widely enough to support improvement. There were no formal systems to help ensure staff learned from significant events/incidents/complaints.
Risks to patients were assessed and well managed, with the exception of those relating to poor management of serious incidents and issues with medicines management (GPs medicines bags).
Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments and that it was very difficult to get through the practice when phoning to make an appointment.
The practice had good facilities and was well equipped to treat patients and meet their needs.
However there were areas of practice where the provider needs to make improvements.
Importantly the provider must
Revise the system for monitoring and responding to complaints to ensure records are complete and accurate, and lessons learned are shared with the wider staff.
Maintain minutes of meetings where GPs discuss significant/untoward events, which include details of actions taken by the practice to prevent future adverse events, lessons learnt from any incident/event and cascade these to the staff team.
Update the process for checking and recording stock levels of emergency medicines held within GP home visit bags.
In addition the provider should:
Improve processes for making appointments.
Chief Inspector of General Practice
We found that a touch screen facility for booking in for an appointment was available for patients as well as reporting to reception so that staff knew they were there. Patients told us the staff treated them respectfully and were helpful. We saw that staff spoke politely to patients and consultations were carried out in private treatment rooms.
We found that the provider could not be sure that all staff were suitable to work with vulnerable patients because not all pre-employment checks had been completed. Patients told us they knew how to make a complaint and that any issues would be taken seriously.