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Inspection Summary


Overall summary & rating

Good

Updated 2 August 2018

This practice is rated as Good overall. (Previous rating February 2018 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Enys Road Surgery on 18 December 2017. The overall rating for the practice was good. The practice was also rated good for the effective, caring, responsive and well-led domains and all the population groups. It was however rated as requires improvement for providing safe services. The full comprehensive report on the December 2017 inspection can be found by selecting the ‘all reports’ link for Enys Road Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 22 June 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 18 December 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.

At our inspection of 18 December 2017, we found that:

The fire risk assessment needed to be updated and all actions taken recorded

An electrical safety risk assessment had been carried out in January 2016 but actions required had not been completed.

At this inspection our key findings were as follows:

A new fire risk assessment had been carried out and actions completed.

All outstanding electrical work had been completed.

Additionally we saw that:

There was now a system for reviewing and monitoring the registration status of all clinical staff on an ongoing basis.

There was a system in place that ensured that a GP checked all prescriptions that had been issued but not picked up before they were destroyed.

The practice was adhering to their recruitment policy.

The practice had reviewed the uptake of pneumococcal vaccine of children aged 2 years and the most recent figures we were shown exceeded the national 90% target.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

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

Inspection areas

Safe

Good

Updated 2 August 2018

We rated the practice as good for providing safe services.

At our previous inspection on 18 December 2017, we rated the practice as requires improvement for providing safe services as:

  • Although a

    fire risk assessment had been completed in September 2014 and reviewed in March 2016, the assessment did not clearly show if all actions had been completed.

  • An electrical

    safety risk assessment had been carried out in January 2016 but actions required had not been completed.

These arrangements had significantly improved when we undertook a follow up inspection on 22 June 2018. The practice is now rated as good for providing safe services.

Track record on safety

The practice had resolved the issues on safety.

  • There were comprehensive risk assessments in relation to safety issues. Actions had been identified, acted upon and recorded.
  • The practice monitored and reviewed safety using information from a range of sources.

Please refer to the evidence tables for further information.

Checks on specific services

Older people

Good

Updated 23 April 2015

The practice is rated as good for the care of older patients. Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people. The practice provided support to high numbers of older patients in the local population. The practice offered proactive, personalised care to meet the needs of the older people in its population. It was responsive to the needs of older people and offered home visits and rapid access appointments for those with enhanced needs.

People with long term conditions

Good

Updated 23 April 2015

The practice is rated as good for the care of people with long-term conditions. Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. Longer appointments and home visits were available when needed. All these patients had a named GP and a structured annual review to check that their health and medication needs were being met. For those people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people

Good

Updated 23 April 2015

The practice is rated as good for the care of families, children and young people. There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations. Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals. Appointments were available outside of school hours and the premises were suitable for children and babies. We saw good examples of joint working with midwives and health visitors.

Working age people (including those recently retired and students)

Good

Updated 23 April 2015

The practice is rated as good for the care of working-age people (including those recently retired and students). The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. The practice provided regular services to students within the local university. The practice provided Chlamydia testing kits and participated in the C card scheme to support patients’ sexual health. The practice was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs for this age group.

People whose circumstances may make them vulnerable

Good

Updated 23 April 2015

The practice is rated as good for the care of people whose circumstances may make them vulnerable. The practice held a register of patients living in vulnerable circumstances including homeless patients, those who were housebound and those with a learning disability. Annual health checks were provided for patients with a learning disability. The practice offered longer appointments for patients with learning disabilities.

The practice worked closely with district nurses and the community matron which enabled an improved continuity of care for their housebound patients. The practice had identified those housebound patients who had not recently engaged with the practice in order to improve the level of care provided to this vulnerable group. Protected time had been made available to enable practice nurses to provide home visits to these patients. The practice regularly worked with multi-disciplinary teams in the case management of adults and children who were vulnerable. The practice had sign-posted these patients to various support groups and voluntary sector organisations. Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in and out of hours. However, many staff had not received training in the safeguarding of vulnerable adults.

People experiencing poor mental health (including people with dementia)

Good

Updated 23 April 2015

The practice is rated as good for the care of patients experiencing poor mental health (including people with dementia). Those patients experiencing poor mental health had received an annual physical health check. The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. The practice carried out advanced care planning for patients with dementia.