Grayshott Surgery

Updated 12 July 2023

Grayshott Surgery is located in Hindhead at:

Boundary Road

Grayshott

Hindhead

Surrey

GU26 6TY

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Surrey Heartland Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of about 12,500. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices, a primary care network, who work together to provide some services to the community such as first contact physiotherapists, weekend and evening appointments with GPs and nurses and a pharmacist based in the surgery

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the highest decile (10 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 2% Asian, 96% White, 0.5% Black and 1.5% Mixed.

The age distribution of the practice population mirrors the local and national averages. However, there are lower numbers of working age people and higher numbers of older people.

There is a team of 9 GPs and a physicians associate. There is a team of 3 nurses and 2 healthcare assistants. The GPs are supported at the practice by a team of reception/administration staff. The practice manager and assistant practice manager provide managerial oversight. The practice is a training practice and at the time of our inspection had 2 registrars attached to the practice. (A training practice has GP trainees who are qualified doctors completing a specialisation in general practice.)

The practice is open between 8 am to 6.30pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally by the primary care network, where late evening and weekend appointments are available. Out of hours services are provided by NHS 111.

Updated 12 July 2023

We carried out an announced, focused inspection at Grayshott Surgery on 4 May 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - not inspected, rating of good carried forward from previous inspection

Responsive - good

Well-led - requires improvement

Following our previous inspection on 5 October 2016, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Grayshott Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

• We inspected the safe, effective, responsive, and well-led questions.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We found that:

• Risks to patients, staff and visitors were not always identified, managed or mitigated effectively.
• Patient group directions were not always appropriately authorised.
• Actions identified by infection control audits carried out had not been addressed.
• The practice did not have a current electrical installation condition report for the premises.
• There were significant gaps in staff training.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• Staff told us they felt well supported and that leaders were approachable.

We found four breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients
• Maintain appropriate standards of hygiene for premises and equipment
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties

The provider should:

• Improve uptake of childhood immunisations.
• Improve uptake of cervical screening.
• Take steps to ensure that all staff have access to regular appraisals.
• Take steps to ensure the backlog of summarising notes is cleared.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care