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Review carried out on 11 July 2019

During an annual regulatory review

We reviewed the information available to us about Cambrian Surgery on 11 July 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 3 October 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cambrian Surgery on 11 May 2016. After the comprehensive inspection, the practice was rated as good overall with requires improvement in providing safe services. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Cambrian Surgery on our website at www.cqc.org.uk. We undertook a focussed follow up inspection on 3 October 2016 to check that improvements had been made. The practice is rated as good for providing safe services and rated good overall.

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, recording and the learning from significant events.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • Risks to patients were assessed and well-managed and full clinical audits completed.
  • For patients on high-risk medicines and those requiring regular medicine reviews, these had been undertaken and systems were in place for medicine review monitoring.
  • Formal system for recording and monitoring medicines that on an ad hoc basis maybe taken by GPs to home visits was in place.
  • An audit about the identification of carers had been conducted and the numbers of carers on the practice register had increased.
  • General health and safety risk assessments had been completed, this included fire risk assessments, maintenance records and Legionella.
  • The practice ensured their recruitment arrangements included Disclosure and Barring Service (DBS) checks were completed for staff who had contact with potentially vulnerable patients including locum GP staff and references were recorded.
  • Staff who provide a chaperone service were in receipt of chaperone training and had a Disclosure and Barring Service (DBS) check completed.
  • Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. Training included a documented induction system and safeguarding adults and children to the appropriate levels as well as basic life support.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 11 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Cambrian Surgery on 11 May 2016. Overall the practice is rated as good.

Our key findings were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients 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.

However, there were also areas of practice where the provider should make improvements:

  • Continue to increase the identification of patients who may be carers.

  • Improve the documentation of the learning, action points and trend analysis for significant incidents and events.

  • Ensure copies of the risk assessments such as fire checks and legionella records that were incomplete or missing from those reviewed are held by the practice.

  • Maintain a full recruitment record at the practice for the locum GPs used.

  • Improve the robustness of the medication review systems as we found that 18.3% of patients on specific medicines used to control blood pressure had not had a monitoring blood test in the last 12 months.

  • Create a formal system for recording and monitoring medicines that on an ad hoc basis maybe taken by GPs to home visits.

  • Complete full clinical audits where any improvements made can be implemented and monitored.

  • Review the practice policies and procedures to ensure they are in line with current best practice, have a review date and are readily available and easily located by staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 30 July 2013

During a routine inspection

We spoke with six patients during our visit. All of the patients we spoke with were generally pleased with the service they received from the practice. One patient said, �Everyone is friendly and polite�. Patients told us that the doctors were approachable and happy to answer their questions.

We saw that the practice had policies and procedures in place to help protect patients� privacy and dignity. The staff we spoke with were familiar with the procedures. None of the patients we spoke with had any concerns in this area.

We found that care and treatment was planned and delivered in a way that met patients� needs and protected their rights. Patients were able to be involved in decisions about their treatment.

We found that patients received their treatment in a clean, hygienic environment. The practice had suitable arrangements in place to ensure patients were not placed at risk of cross infection.

We were satisfied that the provider made all the appropriate checks on staff before their full employment started. The practice manager regularly checked to ensure that healthcare professionals employed at the practice were correctly registered with their appropriate professional body.

We saw that the practice carried out a range of audits on a regular basis to monitor the quality of its own performance and to learn from any mistakes made. The practice had an active and effective patient participation group.