The Care Quality Commission
  • Doctor
  • GP practice

Gordon Street Surgery

Overall: Inadequate read more about inspection ratings

The Surgery, 72 Gordon Street, Burton On Trent, Staffordshire, DE14 2JA (01283) 563175

Provided and run by:
Gordon Street Surgery

All Inspections

15 May 2023

During a routine inspection

We carried out an announced comprehensive inspection at Gordon Street Surgery. Remote clinical searches took place on 10 May 2023 with an onsite inspection on 15 May 2023.

Overall, the practice is rated as inadequate.

Safe - requires improvement.

Effective - requires improvement.

Caring – requires improvement.

Responsive - inadequate

Well-led - inadequate

Our last announced review took place on 22 September 2021 to review the warning notice served to Gordon Street Surgery for breaches under Section 29 of the Health and Social Care Act 2008. We served the warning notice on 1 July 2021 and had required the practice to be compliant with Regulation 19(1) and 19 (2) Fit and Proper Persons employed, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, by 8 September 2021. We reviewed the breach within Schedule Three of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 “all potential and employed staff.” However, we did not review other breaches or re-rate the practice at the 22 September review. Therefore, the ratings from the previous inspection in June 2021 remained unchanged: these ratings were requires improvement overall and inadequate for providing a safe service.

At the inspection on 15 May 2023, we found that some improvements had been made in the areas identified at the previous inspection in providing a safe service, for example:

  • The review and management of the cleaning and routine maintenance of the practice.
  • Formalised supervision arrangements for non-medical prescribers and nursing staff.
  • Recruitment checks to ensure staff had the appropriate qualifications skills and experience necessary for the work they performed and physical/mental health checks to ensure staff were able to carry out their role.
  • Improvements were identified in the significant event reporting and root cause analysis process.

However, gaps remained, for example:

  • Recruitment records were missing references for two staff including checks of conduct in previous employment and a disclosure and barring check was not completed to the level appropriate to the role.
  • Not all staff had achieved safeguarding training at the appropriate level for their role.
  • Significant event trend analysis and sharing learning from these events with the whole team had yet to take place, although it was planned.
  • Nominated staff had not completed fire marshall training, however at the time of the onsite inspection visit, on 15 May 2023, this had been completed.
  • Not all staff had completed dementia awareness training.
  • There was no clear route for inclusion of clinical staff in policies which had a clinical element.

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

Why we carried out this inspection.

We carried out this inspection to follow up breaches of regulation from a previous inspection and to follow up concerns reported to us.

The focus of this inspection included:

  • Safe, Effective, Caring, Responsive and Well led domains.
  • We followed up breaches of regulations and advisory actions identified in the previous inspection and the review.
  • We reviewed external stakeholder and information of concern shared with the Care Quality Commission.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A site visit.
  • Staff questionnaires.
  • Feedback from external stakeholders.

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 found that:

  • The practice respected patients’ privacy and dignity, and patient confidentiality was maintained throughout the practice.
  • The practice did not have clear oversight on the levels of attainment of clinical staff’s safeguarding training.
  • The practice did not have oversight on the level of the disclosure and barring checks of all staff members.
  • The practice had not ensured that all clinical staff had appropriate knowledge and understanding of consent. Some clinical staff had yet to complete Mental Capacity Act 2005 training.
  • Patients expressed difficulty in accessing care and treatment in a timely way.
  • Clinical searches completed showed some gaps in following national guidance.
  • Verbal complaints raised with the practice were not consistently documented.
  • The practice did not always operate effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We found a breach of regulations. The provider must:

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

The provider should:

  • Implement a clear route for inclusion of clinical staff in policies which have a clinical element.
  • Reconcile their safeguard registers to ensure the accuracy of their safeguarding register with the safeguard local authority teams.
  • Put in place a consistent staff exit interview process to inform the practice recruitment and retention process.
  • Provide appropriate training and support for those staff with additional lead roles, such as infection prevention and control.
  • Improve from a single line entry the content in some of the medicine reviews completed by the GPs.
  • Amend clinical staff appraisal to include a clinician to enable discussion on competencies and professional development.
  • Encourage patients to attend their appointments for the national cervical cancer screening programme.
  • Improve involvement of and engagement with the patient population to gain feedback in order to monitor and review the service.

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 vary the provider’s registration 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.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

30 June 2021

During a routine inspection

We carried out an announced inspection at Gordon Street Surgery on 30 June 2021. Overall, the practice is rated as Requires Improvement:

Safe - Inadequate

Effective - Requires Improvement

Caring - Requires Improvement

Responsive - Requires Improvement

Well-led - Requires Improvement

Following our previous desk- top review in March 2021 which was not rated we found a further two breaches of regulations:

Regulation 12 Health and Social Care Act (RA) Regulations 2014 Safe care and Treatment

Regulation 17 HSCA (RA) Regulations 2014 Good governance.

These breaches were in addition to the breach in Regulation 19 12 HSCA (RA) Regulations 2014 Fit and Proper Persons we identified at our last inspection in August 2019.

At our previous full comprehensive inspection in August 2019 we rated the practice as Requires Improvement overall and Requires Improvement for providing safe and responsive services.

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

Why we carried out this inspection

This inspection was a comprehensive inspection which included a site visit to follow up on:

Three breaches of regulations and to review the practices progress with the best practice recommendations we made in March 2021.

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 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 Requires Improvement overall, with the provision of safe services rated as inadequate, and Requires Improvement for all population groups.

We found that:

Since our desk-top review in March 2021 the practice had:

  • Developed clear systems and processes to keep patients safe.
  • Receptionists had been given guidance on identifying deteriorating or acutely unwell patients. They had received training in symptoms they should recognise and were aware of actions to take in respect of symptoms associated with stroke patients.
  • The practice had improved systems to generate assurances for the safe management of patients in shared care arrangements.
  • Had made some improvements towards and had further plans to develop the capacity and skills to deliver high quality, sustainable care.
  • Developed a practice vision. Staff we spoke with knew about the vision and the practice was in the process of developing a credible strategy to support their vision.
  • Taken steps to make change to its culture and was committed to developing an open and supportive culture.

During this inspection in June 2021 we found:

  • The overall governance arrangements remained ineffective, although the practice was developing plans to improve arrangements.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • Cleaning and routine maintenance at the practice had not been carried out as scheduled.
  • The practice did not always act on appropriate and accurate information.
  • We saw evidence of systems and processes for learning, continuous improvement and innovation.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Patients expressed difficulty in accessing care and treatment in a timely way.
  • The practice did not always learn and make improvements when things went wrong. However, they had improved their system to record when things went wrong.
  • There was limited monitoring of the outcomes of care and treatment.
  • The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.

We found two breaches of regulations. The provider must:

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

The areas where the provider should make improvements are:

  • Review and improve how they manage the cleaning and routine maintenance of the practice.
  • Continue to develop, seek and gather patient views to a larger scale to gain feedback on the responsiveness of the service provided to patients.
  • Review and improve how they identify and record people who have caring responsibilities, including young carers.
  • Continue to develop the quality improvement programme with a formalised forward plan.
  • Formalise the supervision arrangements for non-medical prescribers and nursing staff.
  • Follow best practice for DNACPR orders.

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

Review completed 2 March 2021

During an inspection looking at part of the service

This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk considering the Covid-19 pandemic. This was conducted with the consent of the provider.

We obtained the information within in it without visiting the provider.

We previously inspected Gordon Street Surgery on 4 December 2017 and rated it as inadequate. The practice was placed into special measures. We carried out a follow up inspection on 24 July 2018 as part of our inspection programme for services rated as inadequate and placed into special measures to confirm that the practice met the legal requirements in relation to the breaches in regulations that we had identified.

During the July 2018 inspection we found the practice had met the legal requirements but was rated as requires improvement in providing a responsive and well led service and therefore rated as requires improvement overall.

We carried out a full comprehensive inspection on 5 August 2019 as part of inspection programme for practices rated requires improvement. During the August 2019 inspection the practice had met the legal requirements but were still rated as requires improvement overall and requires improvement within the safe and responsive domains.

The full comprehensive reports on the 4 December 2017, 24 July 2018 and August 2019 inspections can be found by selecting the ‘all reports’ link for Gordon Street Surgery on our website www.cqc.org.uk.

We carried out this pilot remote review in response to concerns raised by an external stakeholder about safe and well led domains. During our review we received anonymous concerns from the public about their experiences with the timely issuing of repeat medicines or medicine changes.

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 found that:

  • The practice did not have clear systems and processes to keep patients safe.
  • Receptionists had not been given guidance on identifying deteriorating or acutely unwell patients. They were not aware of actions to take in respect of symptoms associated withstroke patients.
  • The practice did not have adequate assurances for the safe management of patients in shared care arrangements.
  • The practice did not learn and make improvements when things went wrong.
  • There was limited monitoring of the outcomes of care and treatment.
  • The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
  • Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
  • Staff did not know the practice had a vision. The practice vision was not supported by a credible strategy.
  • The practice culture did not effectively support high quality sustainable care.
  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.

The provider must:

• Ensure care and treatment is provided in a safe way to patients.

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

The areas where the provider should make improvements are:

  • Review the practice infection prevention and control policy and supporting audit process.
  • Develop, seek and gather patient views to a larger scale to gain feedback on the responsiveness of the service provided to patients.
  • Review the quality improvement arrangements and develop a clear quality improvement plan.

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

5 August 2019

During a routine inspection

We previously inspected Gordon Street Surgery on 4 December 2017 and rated it as inadequate. The practice was placed into special measures. We carried out a follow up inspection on 24 July 2018 as part of our inspection programme for services rated as inadequate and placed into special measures to confirm that the practice met the legal requirements in relation to the breaches in regulations that we had identified. During the July 2018 inspection we found the practice had met the legal requirements and was rated as requires improvement in providing a responsive and well led service and therefore rated as requires improvement overall. The full comprehensive report on the 4 December 2017 and 24 July 2018 inspections can be found by selecting the ‘all reports’ link for Gordon Street Surgery on our website at 

We completed an announced comprehensive inspection at Gordon Street Surgery on 5 August 2019 as part of our inspection programme for services rated as requires improvement to ensure that the issues identified had been addressed in particular:

  • Develop the staff training matrix to include all in-house training, document the clinical staff competency checks undertaken.
  • Maintain blood thinning medicine monitoring and prescribing in line with the practice protocol.
  • Develop a system to help identify vulnerable adults and Improve clinical practice in coding patients’ medical conditions on the electronic system.
  • Patient paper record security system improvements.
  • Further develop the significant event system and continue to improve the practice carer register numbers.
  • Improve the uptake on the monitoring of long-term condition patients with diabetes and the uptake of cervical and bowel cancer screening.

At this inspection, we found that the provider had satisfactorily addressed or had made progress in most of the issues identified in the July 2018 inspection.

We have rated this practice as requires improvement overall.

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 rated the practice as requires improvement for providing safe services because:

  • There were gaps found in the recruitment records for locum staff and in records of staff vaccination and immunity histories.

We rated the practice as good for providing effective services because:

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • The practice understood the needs of its population and tailored services in response to those needs. There was evidence of a number of projects and services the practice had been involved with to ensure patients’ needs were met.
  • However, the practice needed to continue to improve the uptake of the service offered to patients for the monitoring and management of long-term conditions improvements in cervical cancer screening uptake, diabetes and asthma reviews.

We rated the practice as good for providing a caring service because:

  • Changes had been implemented based on patient feedback for example, the reception front desk was now managed by one reception staff member without telephone responsibilities to improve the patient face to face experience at the practice.
  • In February 2019 a patient satisfaction report for extended hours provision at Gordon Street Surgery showed that patients who responded to the questionnaire were either satisfied or very satisfied with their appointment and the care and support received from the doctor.
  • Only 0.6% of registered patients were electronically coded as being a carer although this had improved since the last inspection in July 2018 from 36 to 61 patients on their carer register.

We rated the practice as requires improvement providing a responsive service because:

  • Although the practice had acted on the National GP survey findings and implemented a number of changes, the impact of these changes had yet to achieve positive patient feedback.
  • The practice had made improvements to its complaint policy and procedures were in line with recognised guidance, trend analysis and learning was derived from these incidents.

We rated the practice as good for providing a well led service because:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure specified information is available regarding each person employed.

The areas where the provider should make improvements are:

  • Continue to improve the identification of carers.
  • Review the practice infection prevention and control policy with reference to communicable diseases.
  • Develop, seek and gather patient views to a larger scale to gain feedback on the responsiveness of the service provided to patients.
  • Implement strategies to improve the uptake for cervical and cancer screening programmes and for the monitoring and management of long-term conditions.

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

24 July 2018

During a routine inspection

We previously carried out an announced comprehensive inspection at Gordon Street Surgery on 4 December 2017. The overall rating for the practice was inadequate. The practice was rated Inadequate in providing safe, responsive and well-led services and requiring improvement in providing effective and caring services. Breaches of legal requirements were found and requirement notices were served in relation to safe care and treatment, good governance and fit and proper persons employed. The practice was placed in special measures. The full comprehensive report on the December 2017 inspection can be found by selecting the ‘all reports’ link for Gordon Street Surgery on our website at .

This inspection was an announced comprehensive inspection carried out on 24 July 2018 as part of our inspection programme for services rated as inadequate and placed into special measures and to confirm that the practice met the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 4 December 2017.

This practice is now rated as Requires Improvement overall.

The key questions are rated as:

Are services safe? –Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those recently retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) – Requires Improvement

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • Patients found access to appointments had improved. However, patients expressed the difficulty they had in telephone access to obtain appointments first thing in the morning.
  • The practice had systems to keep patients safe and safeguarded from the risk of abuse.
  • Staff recruitment practices were in line with legal requirements.
  • Systems had been implemented to ensure that health and safety risk assessments and staff training were completed.
  • Effective systems were in place to monitor training completed by staff.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • The patient participation group was active.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation. There were some gaps in the practice’s governance arrangements.

The areas where the provider should make improvements are:

In managing risks, issues and performance in particular:

  • Develop the staff training matrix to include all in-house training, document the clinical staff competency checks undertaken
  • Maintain blood thinning medicine monitoring and prescribing in line with the practice protocol.
  • Develop a system to help identify vulnerable adults and Improve clinical practice in coding patients’ medical conditions on the electronic system.
  • Patient paper record security system improvements.
  • Further develop the significant event system and continue to improve the practice carer register numbers.
  • Improve the uptake on the monitoring of long-term condition patients with diabetes and the uptake of cervical and bowel cancer screening.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

4 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Inadequate overall. We previously inspected the service in October 2014 and rated the practice as Good.

The key questions are rated as:

Are services safe? –Inadequate

Are services effective? – Requires improvement

Are services caring? – Requires improvement

Are services responsive? – Inadequate

Are services well-led? - Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those recently retired and students – Inadequate

People whose circumstances may make them vulnerable – Inadequate

People experiencing poor mental health (including people with dementia) - Inadequate

We carried out an announced comprehensive inspection at Gordon Street Surgery on 4 December 2017 as part of our inspection programme.

At this inspection we found:

  • The practice had systems, processes and practices in place to protect people from potential abuse. Staff were aware of how to raise a safeguarding concern and had access to internal leads and contacts for external safeguarding agencies. However, not all staff had received safeguarding training relevant to their role.

  • The practice systems to manage risk so that safety incidents were less likely to happen required strengthening.

  • Clinicians knew how to identify and manage patients with severe infections, for example, sepsis.

  • Some patients found it difficult to make an appointment by telephone and told us appointments with GPs did not always run on time.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • The practice ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.

  • There was a system to manage infection prevention and control and patients commented that the practice was always clean. However, there was a lack of evidence to show how the action plan was being monitored to assess progress in meeting the requirements of the Infection Prevention and Control (IPC) audit. The IPC policy did not govern practice.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure specified information is available regarding each person employed.

  • Ensure, where appropriate, persons employed are registered with the relevant professional body.

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

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Carry out fire drills at regular intervals.

  • Increase the identification and support to carers on the practice list.

  • The induction process for new staff staff should include an assessment of competence. The provider should also review the system for induction of locum staff to ensure they are adequately supported to provide safe care and treatment.

  • Review arrangements to protect patient privacy and confidentiality.

  • The provider should review its systems to assure itself that all relevant staff know how to respond appropriately in the event of a safeguarding concern and understand their roles in relation to chaperoning.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

21 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Drs Collier, Robinson, Gunstone, O’Reilly & Rakkiannan on 21 October 2014. Overall the practice is rated as good.

Specifically, we found the practice to be good in providing safe, effective, caring, responsive services and for being well-led. The practice was found to be good for the services it provided to older people, people with long term conditions, families, children and young people, the working age population and those recently retired, people in vulnerable circumstances and people experiencing poor mental health.

Our key findings were as follows:

  • Staff were aware of their responsibilities to raise concerns and report incidents.
  • Patient care and treatment was considered in line with best practice national guidelines.
  • The practice was clean and hygienic and had arrangements in place for reducing the risks from healthcare associated infections.
  • Patients said that they were treated with compassion, dignity and respect. They felt that their GP listened to them and treated them as individuals.
  • The practice had a trained team of staff who had expertise and experience in a wide range of health conditions.
  • The practice encouraged their patients and staff to share their views.

There were some areas of practice where the provider needs to make improvements.

The provider should:

  • Ensure that systems are in place to show that all staff are informed about new guidance. Have a structured approach to meetings to show that sharing and recording of lessons learned from significant events/incidents, and near misses are disseminated to staff. Meetings should be minuted to clearly show what was discussed, action to be taken, by whom and when.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

During a check to make sure that the improvements required had been made

At our previous inspection on 21 August 2013, we saw that the provider did not always have effective systems in place to monitor the quality of its service or manage risks to the health and welfare of its patients.

At this inspection we saw that the provider had responded to patients' concerns and made effective improvements to their service. We saw that risk assessments had been completed to minimise the risks to patients and keep them safe during a medical emergency.

21 August 2013

During a routine inspection

On the day of our inspection we spoke with eight patients and six members of staff. We did this to help us to understand the outcomes and experiences of selected patients who used the practice. One patient told us, 'The service here is absolutely fine. They are quick and thorough. If you have any queries they are happy to help you'. Another patient told us, 'Staff are polite and helpful but getting an appointment is a pain in the neck. Once you get an appointment though everything else is great'.

We saw that patients were treated with dignity and respect and that they experienced care and treatment that met their needs. This was because they were cared for by staff that were supported to deliver care and treatment safely and to an appropriate standard.

We saw that patients were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

The provider had some systems in place for monitoring the quality of service provision but further work was needed to demonstrate compliance with this regulation. We saw that the provider did not always have effective systems in place to monitor the quality of its service or manage risks to the health and welfare of its patients.