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Review carried out on 21 December 2019

During an annual regulatory review

We reviewed the information available to us about Pound House Surgery on 21 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 We have not revisited the practice as part of this review because the practice was able to demonstrate that they were meeting the regulations associated with the Health and Social Care Act 2008 without the need for a visit.

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

At our previous comprehensive inspection at Pound House Surgery in Wooburn Green, Buckinghamshire on 28 October 2016 we found a breach of regulations relating to the provision of safe services. The overall rating for the practice was good. Specifically, the practice was rated requires improvement for the provision of safe services and good for the provision of effective, caring, responsive and well-led services. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Pound House Surgery on our website at

This inspection was a desk-based review carried out on 4 December 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection in October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

We found the practice had made improvements since our last inspection. Using information provided by the practice we found the practice was now meeting the regulations that had previously been breached. We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well-led services.

Our key findings were as follows:

  • We saw the practice had reviewed existing health and safety arrangements and environmental risks at both the main practice in Wooburn Green and the branch surgery in Bourne End. For example, gas safety checks and electrical installation checks had been undertaken and supporting correspondence recorded.

  • Revised recruitment policies and processes had been adopted which reflected national guidance. For example, supporting recruitment documentation (Disclosure and Baring Service checks) that was pending during the October 2016 inspection was now all recorded and documented correctly. The practice had also reviewed and amended the supporting policy which reflected updated guidance. Disclosure and Baring Service checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

  • The practice had reviewed and updated the arrangements to record, share and action (where appropriate) medicine and other patient safety alerts. Specifically, practice had subscribed to receive alerts from Medicines and Healthcare Products Regulatory Agency.

  • Further steps had been taken steps to comprehensively track and monitor the security of all prescription stationary. This included a system to log the location of prescription stationary once transferred to the branch surgery.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 28 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Pound House Surgery on 28 October 2016. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Opportunities for learning from internal incidents were maximised.
  • Some risks to patients who used services were assessed and managed. However, not all reasonable steps were taken to assess and mitigate risks in relation to receiving and responding to patient safety alerts, Disclosure and Barring Checks, tracking and storing blank prescriptions, and maintenance and record keeping for the premises.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. However, not all staff had received training updates in a timely fashion.
  • Exception reporting rates were relatively high for heart failure and osteoporosis compared to CCG and national averages. The practice had taken a number of measures to try and reduce exception reporting rates.
  • 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.
  • 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 an area of outstanding practice:

  • The practice had developed a comprehensive strategy to further identify and improve outcomes for patients with dementia. The practice provided dementia screening, referrals to other services, and information about support organisations. The practice had conducted 335 dementia assessments since April 2016 and this resulted in 72 diagnoses of dementia. One GP and a member of reception staff were dementia champions and they had developed information packs for patients with dementia and their families. The practice had provided staff with training about dementia and identified and implemented measures to ensure the practice and environment were more dementia friendly. QOF figures for 2015 to 2016 showed that 94% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is higher than the CCG average of 85% and national average of 84%.

The areas where the provider must make improvement are:

  • Complete required actions identified in the fire risk assessment, such as undertaking and documenting an electrical installation check for both premises.
  • Ensure that appropriate building checks and maintenance are undertaken and documented for both premises to include gas safety checks.

The areas where the provider should make improvement are:

  • Ensure staff receive DBS checks appropriate to their role or that appropriate assessments are undertaken to determine whether these are required and to identify and mitigate risks.
  • Ensure that there are adequate systems for receiving and actioning all patient safety alerts.
  • Embed systems to ensure that the location of all blank prescriptions is comprehensively tracked and that all blank prescriptions are stored securely.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice