We carried out a review of the data available to us about Limefield and Cherry Tree Surgeries 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 Limefield and Cherry Tree Surgeries, you can give feedback on this service.
We carried out an announced focused inspection at Limefield and Cherry Tree Surgeries on 20 June 2019. We decided to undertake this inspection following our annual review of the information available to us. This inspection looked at the following key questions; Safe, Effective and Well Led.
We based our judgement of the quality of care at this service on a combination of:
We have rated this practice as good overall and good for all population groups.
We found that:
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
We carried out an announced comprehensive inspection at Limefield and Cherry Tree Surgeries on 21 June 2017. The overall rating for the practice was requires improvement and a requirement notice was issued for a breach to regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The full comprehensive report on the June 2017 inspection can be found by selecting the ‘all reports’ link for Limefield and Cherry Tree Surgeries on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 30 January 2018 to confirm that the practice had carried out its plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 21 June 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:
The practice had made improvements to its systems around managing, recording and mitigating risks. Fire and legionella risk assessments had been documented for both the main and branch sites and mitigating actions completed as appropriate.
We saw recruitment checks for a newly employed member of reception staff were comprehensive.
Prescription stationery was stored securely and systems to log its location and monitor use had been improved and were working effectively.
The practice had implemented a new appointment system incorporating GP telephone triage, with the majority of patients receiving a call back from a GP within 30 minutes of contacting the practice.
The practice’s systems around managing complaints had been embedded and were working well.
However, there were also areas of practice where the provider should make improvements:
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Limefield and Cherry Tree Surgeries on 7 October 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. As a result of the October 2016 inspection visit we issued the practice with requirement notices for breaches to regulation 12 (safe care and treatment) and regulation 19 (fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also issued a warning notice to the provider in respect regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and informed them that they must become compliant with the law by 10 March 2017 with regards to this breach. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Limefield and Cherry Tree Surgeries on our website at www.cqc.org.uk.
This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 21 June 2017. We saw that improvements had been made. Overall the practice is now rated as Requires Improvement.
Our key findings were as follows:
There were improved systems to ensure that significant events were recorded and analysed thoroughly and learning outcomes maximised.
While other systems and processes to keep patients and staff safe had improved, there still remained gaps, for example a fire risk assessment had not been completed at the time of inspection and appropriate recruitment checks had not been carried out for the most recently employed member of staff.
Blank prescription pads were secured securely but there were not effective systems in place at the time of our visit to monitor their location and use.
The governance arrangements in the practice had improved, although further improvements were necessary.
Managerial oversight around staff training was more thorough and most of the training records we asked to view were available.
The practice had begun to implement a programme of appraisal meetings with staff. Five of the eleven staff had received appraisals since our previous visit.
The practice was able to demonstrate how quality improvement work was undertaken.
Patients were positive about their interactions with staff during face to face consultations and said they were treated with compassion and dignity.
Some patients we spoke with continued to express frustration with the practice’s appointment system. This had been discussed at a recent meeting with the patient participation group and the practice told us they planned to review the appointment system in the near future.
There were areas of practice where the provider needs to make improvements.
Importantly, the provider must:
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care, in particular but not exclusively relating to the completion of appropriate fire risk assessments for all practice premises and the implementation of appropriate systems to monitor the location and use of prescription paper.
In addition the provider should:
Actions identified as part of the infection prevention and control audit should be documented as part of an action plan to allow for effective monitoring and timely completion.
Continue to identify and support patients who are also carers
Update the practice website as to the availability of extended hours appointments.
I am taking this service out of special measures. This recognises the improvements made to the quality of care provided by the service.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Limefield and Cherry Tree Surgeries on 7 October 2016. Overall the practice is rated as inadequate.
Our key findings across all the areas we inspected were as follows:
Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment and actions identified to address concerns with infection control practice had not been taken.
There was not a systematic approach to assessing and managing risks. For example, a fire risk assessment was not available. Where risks had been identified, appropriate mitigating action had not been completed.
While we saw that significant events were analysed and some actions identified to reduce the possibility of the events being repeated, we found that the analysis undertaken was not always thorough so learning was not maximised.
The governance arrangements within the practice were insufficient. Many policies were overdue a review and not all were detailed enough to adequately describe the activity to which they related.
There was a lack of managerial oversight around staff training and training needs. Evidence that all staff had received training in safeguarding patients from abuse was not available.
Many staff had not had an appraisal for over a year.
There was limited evidence that audit was driving improvement in patient outcomes.
Patients were positive about their interactions with staff during face to face consultations and said they were treated with compassion and dignity.
Some patients expressed frustration with the practice’s appointment system. They told us they found telephone triage appointments impersonal.
Staff told us they felt supported by the GP and management staff.
The areas where the provider must make improvements are:
Implement effective processes for reporting, recording, acting on and monitoring significant events, incidents and near misses.
Ensure regular infection prevention and control audits are completed.
Ensure recruitment arrangements include all necessary employment checks for all staff.
Carry out quality improvement initiatives which may include clinical audits, and re-audits, to ensure improvements to care and treatment have been achieved and sustained.
Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision. Once identified, take appropriate mitigating action to manage risks.
Ensure appropriate policies and procedures are available to staff which reflect current guidance and the activities undertaken at the practice.
Improve the management and monitoring of staff training so that all staff are trained to ensure they have the skills and qualifications to carry out their roles.
The practice’s own complaints process should be followed when managing patient’s complaints.
The areas where the provider should make improvement are:
I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.
The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.
Special measures will give people who use the service the reassurance that the care they get should improve.
Chief Inspector of General Practice