The Care Quality Commission
  • Doctor
  • GP practice

Trescobeas Surgery

Overall: Good read more about inspection ratings

Trescobeas Road, Falmouth, Cornwall, TR11 2UN (01326) 315615

Provided and run by:
Trescobeas Surgery

All Inspections

18 May 2022

During an inspection looking at part of the service

We carried out an announced inspection at Trescobeas Surgery on 18 May 2022. Overall, the practice is rated as Good.

We have rated each key question as

Safe - Good

Effective - Good

Well-led - Good

Following our previous inspection on 23 June 2021 the practice was rated Requires Improvement overall and for the safe, effective and well led domains. The caring and responsive domains were rated as good.

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

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short 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 have rated this practice as Good overall

We found that:

  • The practice had embedded systems and process that were not in place at the previous inspection.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • 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.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

Whilst we found no breaches of regulations, the provider should:

  • Monitor the systems put in place to improve uptake of cervical screening to ensure they

are effective.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

23 June 2021

During a routine inspection

We carried out an announced inspection at Trescobeas Surgery on 23 June 2021. Overall, the practice is rated as Requires Improvement

Set out the ratings for each key question

Safe - Requires Improvement

Effective - Requires Improvement.

Caring - Good

Responsive - Good

Well-led – Requires Improvement

We carried out a focused inspection through the GP focused inspection pilot (GPFIP) on 17 December 2020. This was in response to intelligence we received from the Kernow Commissioning Group to suggest an increase in risk to patients at the practice. In order to seek assurances around potential risks to patients, we undertook a remote inspection and gathered evidence without entering the practice premises. We found unsafe care and treatment and poor governance and issued two requirement notices to drive improvement.

We did not rate the practice during this assessment as we did not visit the provider.

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

How we carried out the inspection.

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit
  • Staff Questionnaires

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 have rated this practice as Requires Improvement overall, good for responsive, and caring and requires improvement for safe, effective and well led. We rated all population groups as good, except people with long term conditions and families, children and young people which we rated requires improvement.

We found that:

The service is now rated as requires improvement for providing safe services because:

  • Clinical coding in the past had not always been completed effectively and there was a need for consistency to ensure patient safety.

  • Not all clinical staff had undertaken safeguarding training appropriate for their role.

  • The practice did not have an effective system to respond to all patient safety alerts..

The service is now rated as requires improvement for providing effective services because:

  • The was a limited programme of quality improvement activity.

  • The practice’s data for the care of patients with some long term conditions had not been managed effectively.

The service is rated as requires improvement for providing well led services because:

  • New processes put in place needed to be embedded and audited for assurance.

  • There was a new leadership team who acknowledged that improvements were required to promote delivery of high-quality care and had taken some action to

address this. However, not all actions had been embedded and further improvements were required.

However we also found:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

  • Continue to audit previous records to ensure coding and other entries are reviewed to ensure that care and treatment is provided in a safe way.

Whilst we found no breaches of regulations, the provider should:

  • Improve the identification of carers to enable this group of patients to access the care and support they need.

  • Review and monitor cervical screening uptake rates and continue to encourage eligible women to attend for screening.

  • Review processes to improve uptake for childhood immunisations.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

17 December 2020

During an inspection looking at part of the service

In light of the current Covid-19, CQC has looked at ways to fulfil our regulatory obligations, respond to risk and reduce the burden placed on practices by minimising the time inspection teams spend on site.

In order to seek assurances around potential risks to patients, we are currently piloting a process of remote working as far as practicable. This practice consented to take part in this pilot and the evidence in the report was gathered without entering the practice premises.

We carried out the remote elements of inspection through the GP focused inspection pilot (GPFIP) on 17 December 2020. This was in response to intelligence we received from the Kernow Commissioning Group to suggest an increase in risk to patients at the practice. This information included an email account with over 5,000 emails relating to patients being unopened and one weeks missing consultation records. A whistle-blower also informed us of other failings around governance within the practice. From information and potential concerns considered by CQC there were areas identified that required investigation and review.

We have not rated the practice during this assessment as we did not visit the Provider.

We found that:

The practice did not have clear systems and processes to keep patients safe.

  • The practice did not have appropriate systems in place for the safe management of medicines.

  • There was not a process in place for monitoring patients’ health in relation to the use of medicines including high risk medicines (for example, warfarin, methotrexate and lithium) with appropriate monitoring and clinical review prior to prescribing.

  • There was no clear system in place to ensure all patients received an annual review of their medicines which meant there was a risk of some patients being missed.

  • The practice did not manage safety alerts or provide evidence that patient medical alerts were actioned and managed appropriately.

  • Clinicians did not have access to consultation history and previous clinical actions to ensure they were able to deliver safe care and treatment.

  • Effective systems and processes to ensure good governance were not in place.

Following this inspection and due to the seriousness of the concerns found the CQC, served a Letter of Intent under Section 31 of the Health and Social Care Act 2008. This was because “the Commission has reasonable cause to believe that unless it acts under this section any person will or may be exposed to the risk of harm”. This letter offered the registered provider the opportunity to put forward documentary evidence which may provide assurance that the risks identified had already been removed or were immediately being removed.

Following on from the inspection the practice submitted to us an action plan outlining how they would make the necessary improvements to comply with our findings.

The provider must:

  • Ensure that care and treatment is provided in a safe way. (Please refer to the enforcement section at the end of the report for more detail.)

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. (Please refer to the enforcement section at the end of

the report for more detail.)

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

16 November 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 Trescobeas Surgery on 26 May 2016. The practice was rated as requires improvement for safe and good for effective, caring, responsive and well led. Overall the practice was rated as good.

During that inspection we found that the practice was not compliant with the legislation in relation to the secure storage and monitoring of prescriptions.

We also identified that the areas the provider should make improvement were;

  • Ensure systems which identify record and support patients who are also carers.

  • Ensure equipment, including needles and syringes that were accessible to patients, are stored securely.

  • Ensure that staff employed at the practice have the required employment checks.

The report setting out the findings of the inspection was published in August 2016. Following the inspection we asked the practice to provide an action plan detailing how they would improve on the areas of concern.

We carried out a focused inspection of Trescobeas Surgery on 16 November 2016 to ensure the changes the practice told us they would make had been implemented and to apply an updated rating.

We found the practice had made significant improvement since our last inspection on 26 May 2016. Following this focused Inspection we rated the practice as good for providing safe services. The overall rating for the practice remains good. For this reason we have only rated the location for the key question to which this related. This report should be read in conjunction with the full inspection report published August 2016.

At this inspection we found:

  • All prescription stationary was managed, monitored and stored securely.

  • Equipment, including needles and syringes, were stored securely in areas that were not accessible to patients.

  • The practice had completed appropriate employment checks when recruiting new staff.

The provider had also:

  • Accurately identified an increased number of carers and had a dedicated Carers lead. The practice demonstrated that they were continuously actively seeking to identify and support carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

26 May 2016.

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Trescobeas Surgery on 26 May 2016. Overall the practice is rated as good.

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 and recording significant events.
  • Risks to patients were assessed and well managed with the exception of those relating to recruitment checks and the safe storage of blank prescription forms.
  • 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 received about the practice prior to and during the inspection demonstrated the practice performed comparatively and in some instances better when compared with all other practices within the clinical commissioning group (CCG) area. These areas included caring for patients with complex mental health needs and annual health checks of patients with a learning disability.

  • 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.

We saw four areas of outstanding practice:

  • Their was a proactive approach to understanding the needs of different groups of people and to deliver care in a way that met the needs and promoted equality. The practice had a responsive and proactive approach to understanding the needs of younger people using innovative approaches to providing integrated person-centred pathways of care. For example, the practice held termly meetings with Falmouth Exeter University (FXU) pastoral and student services departments to improve and tailor their services. The practice also held well-being days at the FXU site, had a dedicated young person’s champion, (young PPG member) with dedicated websites and twitter and Facebook pages to keep young people informed.

  • The practice was SAVVY level three accredited, one of only 2 services to achieve this level; ensuring services were young person friendly in every aspect of service delivery. SAVVY Kernow, is a local scheme which encouraged young people to become savvy and seek help and advice about their health, wellbeing or everyday life.

  • Leaders had an inspring shared purpose and strove to deliver and motivate staff to succeed. There was a clear proactive approach to seeking out and embedding new ways of providing care and treatment. Weekly huddle meetings took place when the practice was closed so there were no distractions. The practice manager sent all staff a weekly update bulletin by email. This provided them with any information about the practice including staffing matters, training opportunities, and any changes within the practice. Staff were also regularly asked for their opinion of the practice and areas where improvements could be made. They said they felt comfortable making suggestions and felt listened to by the management team.

  • The lead practice nurse was the dedicated hospital discharge liaison nurse. They screened all discharge summaries and coordinated care and medicines for vulnerable people from the practice leaving hospital. This sometimes included a home visit.

The areas where the provider must make improvement are:

  • Ensure systems are put in place to ensure the security and monitoring of prescription forms.

The area where the provider should make improvement are:

  • Ensure systems which identify record and support patients who are also carers.

  • Ensure equipment, including needles and syringes that were accessible to patients,are stored in securely.

  • Ensure that staff employed at the practice have the required employment checks.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice