The Care Quality Commission
  • Doctor
  • GP practice

Mendip Country Practice

Overall: Good read more about inspection ratings

Church Street, Coleford, Radstock, Somerset, BA3 5NQ (01373) 812244

Provided and run by:
Mendip Country Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Mendip Country Practice 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 Mendip Country Practice, you can give feedback on this service.

28 March 2020

During an annual regulatory review

We reviewed the information available to us about Mendip Country Practice on 28 March 2020. 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.

8 August 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Mendip Country Practice on 20 September 2016. The practice was rated as requiring improvement for providing safe services; and was rated as good for providing effective, caring, responsive and well-led services. As a result, the practice was given an overall good rating. Following the comprehensive inspection we issued a requirement, due to a breach of Regulation 12 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to safe care and treatment.

Within our last inspection report we stated that the provider must:

  • Ensure proper and safe management of medicines including arrangements for temperature checks of vaccine storage and action where temperatures are found to be outside the acceptable range.
  • Ensure patients are kept safe by staff who had a Disclosure and Barring Service (DBS) check to act as chaperones; and arrangements are understood and consistently applied by all staff.

In addition, we stated that the provider should:

  • Review arrangements to assess areas of ‘near misses’ in the dispensary in order to identify trends and take action to prevent, where possible, future occurrences.
  • Review health and safety arrangements for use of cryogenic substances.
  • Review arrangements to ensure all staff receive regular appraisals.

The full comprehensive report on 20 September 2016 inspection can be found by selecting the ‘all reports’ link for Mendip Country Practice on our website at www.cqc.org.uk.

We undertook a focused follow-up inspection of the practice on 8 August 2017. The inspection was to confirm that the practice had implemented its action plan to meet the legal requirements in relation to the regulatory breaches that we identified in our previous inspection on 20 September 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

There were key findings across all areas we inspected during this follow-up inspection. We saw documentary and other evidence that:

  • The practice had a record of appropriate actions to be taken if vaccine fridge temperatures were outside the acceptable range.
  • The practice reviewed its chaperone policy so that only trained staff with a Disclosure and Barring Service (DBS) check would act as patient chaperones. When we spoke to staff who act as chaperones, arrangements were understood and consistently applied.
  • The practice monitors and records ‘near misses’ in the dispensary in order to identify trends and take action to prevent future occurrences.
  • A Control of Substances Hazardous to Health (CoSHH) risk assessment was in place for cryogenic substances.
  • The practice reviewed arrangements to monitor and ensure that all staff received a regular annual appraisal. During our focused follow up inspection, we saw documentary evidence that appraisals for all staff were completed before the end of 2016, or were scheduled for completion in 2017. We saw the practice had a system in place to monitor when appraisals were due.

Following this inspection the practice was rated as good across all domains, and its overall rating remained unchanged.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

20 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

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

  • The practice had an open and transparent approach to safety and an effective system in place for reporting and recording significant events. All opportunities for learning from internal and external incidents were maximised.
  • The practice had a strong commitment to learning and development for staff and GPs and we saw examples of this throughout the practice.
  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, a specialist tissue viability nurse visits the practice every week to advise and actively support nurses to treat patients.
  • Risks to patients were assessed and well managed. We saw evidence of effective working with other health professionals, including safeguarding of adults and children.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Feedback from patients about their care was consistently positive. Patients told us that staff went the extra mile and the care that they received exceeded their expectations.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs. Staff from Health Connectors Mendip attend the practice for 4 hours every week, they signpost patients to local groups and services including the British Legion, community transport links and counselling services. This can promote social, emotional and holistic well-being of patients.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group (PPG). The PPG told us that following their suggestion, the practice implemented clearer signage to support people who experience confusion or memory issues.
  • 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. However, we found gaps in the safe storage of medicines and management oversight of this.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • We saw evidence that significant events and complaints were investigated thoroughly and patients received apologies where appropriate.
  • Robust emergency and business continuity plans were in place, appropriate to the rural location and regular, severe adverse weather events.
  • Evidence of support to patients regarding their sexual health and providing emergency contraception.
  • Evidence was in place of thorough and detailed recording in patient records.
  • The dispensary team were experienced and qualified; and supported by GPs and Somerset Clinical Commissioning Group. The dispensary had systems in place to manage and supply medicines to patients and they had a comprehensive set of standard operating procedures (SOPs) which were up to date and reflected current practice.
  • The practice actively reviewed complaints and significant events and how they are managed and responded to, and made improvements as a result.

The areas where the provider must make improvement are:

  • Ensure proper and safe management of medicines including arrangements for temperature checks of vaccine storage and action where temperatures are found to be outside the acceptable range.
  • Ensure patients are kept safe by only using trained and DBS checked staff to act as chaperones; and arrangements are understood and consistently applied by all staff.

The areas where the provider should make improvement are:

  • Review arrangements to assess areas of near misses in the dispensary in order to identify trends and take action to prevent, where possible, future occurrences.
  • Review health and safety arrangements for use of cryogenic substances.
  • Review arrangements to ensure all staff receive regular appraisal.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice