The Care Quality Commission
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  • GP practice

Archived: Yalding Surgery

Overall: Requires improvement read more about inspection ratings

Burgess Bank, Benover Road, Maidstone, Kent, ME18 6ES (01622) 814380

Provided and run by:
Dr's Fincham, Scott and Patosaari

All Inspections

22 March 2018

During a routine inspection

This practice is rated as requires improvement overall. (Previous inspection 25 July 2016 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

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

We carried out an announced comprehensive inspection at Yalding Surgery on 22 March 2018, under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

  • The practice had implemented a system to ensure safety alerts were disseminated and acted on.
  • The practice was unable to demonstrate that all appropriate recruitment checks had been undertaken prior to employment of staff.
  • Risks to patients, staff and visitors were not always assessed and managed in an effective and timely manner.
  • The practice had implemented a system to manage significant events. When incidents did happen, the practice learned from them and improved their processes. However, the completed significant event forms we reviewed lacked detail of the lessons learned and follow-up of the event.
  • The practice was equipped to treat patients and meet their needs. However, not all equipment for use in an emergency was sterile and fit for purpose.
  • The practice 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 had used clinical audit to drive improvements in patient outcomes.
  • The practice had continued to identify and support more patients who were also carers.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use.
  • Governance arrangements were not always sufficient or effectively implemented.

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

  • 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:

  • Continue to ensure that a member of the practice management team completes legionella awareness training.

  • Continue to monitor and improve systems for reporting childhood immunisation rates.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

23 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Yalding Surgery on 12 January 2016. Breaches of the legal requirements were found, in that:

The practices systems and processes were not fully established and operated effectively to enable the practice to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others. For example, issues identified with the management of medicines, fire risk assessments and legionella testing and risk assessments having not been carried out.

Additionally, the practice did not have appropriate storage facilities in order to ensure the confidentiality of patients’ records, which were in paper format.

As a result, care and treatment was not always provided in a safe and well-led way for patients. Therefore, Requirement Notices were served in relation to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation12 - Safe care and treatment and Regulation 17 - Good governance.

Following the comprehensive inspection, the practice wrote to us to tell us what they would do to meet the legal requirements in relation to the breaches and how they would comply with the legal requirements, as set out in the Requirement Notices.

We undertook this desk based inspection on 23 May 2016, to check that the practice had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Yalding Surgery on our website at www.cqc.org.uk

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Yalding Surgery on 12 January 2016. Overall the practice is rated as requires improvement.

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

  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles.
  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
  • All risks to patients were not consistently assessed and well managed. For example, issues with the management of medicines had not been identified, fire risk assessments had failed to identify risks associated with fire doors that had been propped open and the practice was unable to demonstrate a legionella risk assessment had been carried out.
  • Patients’ records that contained confidential information were not always held in a secure way so that only authorised staff could access them.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to help ensure that they met people’s needs.
  • Urgent appointments were available the same day and pre bookable appointments were available up to 12 weeks in advance.
  • 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.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand.
  • There was a business plan that was monitored, regularly reviewed and discussed with all staff. High standards were promoted and owned by all practice staff with evidence of team working across all roles.
  • There was a clear leadership structure and staff felt supported by management.

The areas where the provider must make improvements are:

  • Ensure that risk management includes all infection control and fire risks.

  • Ensure that medicine management processes and systems are reviewed and actions taken to ensure identified risks are addressed.

  • Ensure that records containing confidential patient information are held securely so that only authorised staff can access them.

In addition the provider should:

  • Review the new employee induction programme, to ensure that it is formally recorded.

  • Review staff recruitment procedures to ensure all staff are in receipt of a job description.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice