The Care Quality Commission
  • Doctor
  • GP practice

Pirbright Surgery

Overall: Good read more about inspection ratings

The Old Vicarage, The Green, Pirbright, Woking, Surrey, GU24 0JE (01483) 474473

Provided and run by:
Pirbright Surgery

All Inspections

6 July 2023

During a monthly review of our data

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

27 February 2020

During an annual regulatory review

We reviewed the information available to us about Pirbright Surgery on 27 February 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.

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 Pirbright Surgery in Woking, Surrey on 6 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 Pirbright Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 3 August 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:

  • The practice had reviewed existing arrangements regarding staff training, specifically safeguarding and infection control training. We saw all staff had completed training appropriate to their job role, for example the GPs all had completed Safeguarding Children level three training.
  • The practice had revised recruitment policies and processes which reflected national guidance. For example, supporting recruitment documentation which was missing during the October 2016 inspection had now all been recorded and documented correctly. Furthermore, the practice had reviewed and embedded a practice specific Disclosure and Baring Service (DBS) policy, which was supported by formal risk assessments.
  • The practice had established and was now operating safe systems to assess, manage and mitigate the associated risks relating to the management of medicines. This included implementation of a standardised fridge monitoring template which was now used within the practice and dispensary.
  • A formalised system had been implemented which ensured results were received for all samples sent for the cervical screening programme.
  • The practice had reviewed the range of emergency medicines held on site. We saw the practice now had appropriate arrangements in place to respond to emergencies and major incidents.
  • There was now an effective system in place for reporting and recording significant events. The practice had strengthened the existing significant event reporting procedure, which now included electronically recorded minutes and actions from the significant event meetings.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

6 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pirbright Surgery on 6 October 2016. Overall the practice is rated as good.

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

  • The practice had reviewed the needs of its local population and
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • There was a proactive approach to understanding the needs of different groups of people and to deliver care in a way that meets these needs and promotes equality. This included people who are in vulnerable circumstances or who have complex needs.
  • Information about services and how to complain was available and easy to understand. There was active review of complaints and how they were managed and responded to, and improvements are made as a result. People who use services were involved in the review.
  • Patients could access appointments and services in a way and at a time that suited them. 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 and flexible appointments were offered to patients who would benefit from them.
  • The involvement of other organisations and the local community was integral to how services were planned and ensured that services meet people’s needs.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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 managed, with the exception of those relating to recruitment checks, training and medicines management.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Most staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • 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 one area of outstanding practice:

The practice was working towards a Pace setter award for children and young people (Pace setter is an improvement programme for primary care) and as part of this had worked with a focus group from this population group. We saw the practice worked proactively with their patient participation group and the local council to produce signs for a nearby playground giving users advice on what to do if there was an accident or injury.

The areas where the provider must make improvement are:

  • Ensure that all staff complete training appropriate to their job role, including safeguarding and infection control training.
  • Ensure that all required recruitment checks are completed.
  • Ensure that appropriate systems are put in place to ensure stock rotation and monitoring of expiry dates of vaccines. Protocols used to monitor fridge temperatures should be standardised in accordance with manufacturer’s instructions.

The areas where the provider should make improvement are:

  • Ensure there is a system in place to ensure results are received for all samples sent for the cervical screening programme.
  • Review the emergency medicines held on site.
  • Review how significant event analysis and the resulting action plans are recorded.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice