The Care Quality Commission
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Archived: Eldene Surgery

Overall: Good read more about inspection ratings

Colingsmead, Swindon, Wiltshire, SN3 3TQ (01793) 522710

Provided and run by:
Eldene Surgery

Important: The provider of this service changed. See new profile

All Inspections

20 March 2018

During a routine inspection

This practice is rated as Good overall. (Previous inspection 15 September and 3 October 2017 Requires Improvement )

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

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 – Good

People with long-term conditions – Good

Families, children and young people – Good

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

People whose circumstances may make them vulnerable – Good

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

We carried out an announced comprehensive inspection at Eldene Surgery on 20 March 2018. When we undertook a comprehensive inspection of Eldene Surgery in September 2017 we found areas of concern. The practice was rated as Good for Caring, and Requires Improvement for Safe, Effective, Responsive and Well led. The practice had submitted an action plan detailing the actions they were taking to meet legal requirements. All reports for the practice can be found by selecting the ‘all reports’ link for Eldene Surgery on our website at www.cqc.org.uk.

This report covers the comprehensive inspection we carried out at Eldene Surgery on 20 March 2018 to check whether the practice had completed the actions they told us they would take to comply with all regulations.

At this inspection we found:

  • The practice had 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 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 had a comprehensive programme of clinical audit which drove quality improvements.
  • The practice had initiated a process whereby nurses attended peer review sessions with nurses from nearby practices. This enabled reflection and sharing of good practice to improve patient care.

  • Comment cards received and patients spoken with, reflected that staff involved and treated patients with compassion, kindness, dignity and respect.
  • The practice had taken actions to improve patient access, for example introducing additional telephone lines and employing additional staff.

The areas where the provider should make improvements are:

  • Review systems and processes so that governance is consistently embedded and effective.


Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

15 September and 3 October 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Eldene Surgery on 15 September and 3 October 2017. Overall the practice is rated as requires improvement.

When we undertook a comprehensive inspection of Eldene Surgery in February 2017 we found areas of concern. The practice was rated as good for effective, requires improvement for safe, caring and responsive and inadequate for well led. The practice was served two warning notices on 6 March 2017.The warning notices served related to Regulation 18 Staffing and Regulation 17 Good Governance of the Health and Social Care Act 2008. The practice had submitted an action plan detailing the actions they were taking to meet legal requirements. A focused inspection was carried out on 2 August 2017 to follow up on the warning notice relating to Regulation 18 staffing where concerns were again identified and a requirement notice was served.

These reports can be found by selecting the ‘all reports’ link for Eldene Surgery on our website at www.cqc.org.uk.

This report covers the comprehensive inspection we carried out at Eldene Surgery on 15 September an 3 October 2017 to follow up on the warning notice in relation to Regulation 17- Good Governance and to check whether the practice had completed the actions they told us they would take to comply with all regulations. We found the practice had made progress in achieving their improvement plan but found issues of continuing concern and have rated the practice as requires improvement overall.

Our key findings were as follows:

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.

  • The practice had systems to minimise risks to patient safety but these did not always operate effectively, for example in relation to medicine safety alerts and infection prevention control.

  • Updated protocols and policies had recently been implemented and there had not been time for these to be sufficiently embedded within the practice at the time of the inspection.

  • Staff had completed essential training. However there was no system in place that enabled the management team to have oversight of when role specific training needed updating and whether it had been undertaken.

  • A nurse had been recruited to manage the nursing team who did not have general practice experience, leadership or appraisal skills.

  • Appropriate recruitment checks had been carried out.

  • Results from the national GP patient survey showed improvements in areas relating to care and treatment, but worsening results relating to patient access during lunchtime and via the telephone.

  • There was limited evidence of clinical audit that improved patient outcomes.

  • There was a leadership structure and staff felt better supported by management.

  • Communication between staff and management had improved.

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

Importantly, the provider must:

  • Ensure systems and processes are reviewed to ensure safe care and treatment for service users.

  • Seek and act on feedback received about the services provided.

  • Ensure the practice assess the risks relating to the health, safety and welfare of patients, staff and visitors to the practice and have plans that ensure adequate measures are taken to minimise those risks.

  • Ensure arrangements in respect of staff support and training are reviewed.

In addition the provider should:

  • Review systems for identifying and supporting vulnerable patients such as carers and those recently bereaved.

  • Ensure assurance and oversight of recruitment checks undertaken by the human resources department and role specific training requirements for clinical staff are maintained within the practice.

  • Ensure patient group directives for the safe provision of immunisations are correctly adopted.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

2 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 at Eldene Surgery on 2 February 2017. The overall rating for the practice was rated as requires improvement. The full comprehensive report on the February 2017 inspection can be found by selecting the ‘all reports’ link for Eldene Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 2 August 2017 to follow up on a warning notice the Care Quality Commission served following the comprehensive inspection in February 2017. On 6 March 2017we issued two warning notices. The warning notices served related to Regulation 18 Staffing and Regulation 17 Good Governance of the Health and Social Care Act 2008. The practice was required to correct the regulatory breaches set out in the warning notice relating to Regulation 18 by 31 July 2017. The practice had submitted an action plan detailing the actions they were taking to meet legal requirements. This report covers our findings in relation to those requirements. Due to the focussed nature of this inspection the ratings for the practice have not been updated. We will conduct a comprehensive inspection to follow up on the warning notice relating to Regulation 17 within the timescales stated in the warning notice and to determine their compliance with all requirements of the Health and Social Care Act 2008.

We found action had been taken in respect of the warning notice, however there were areas within the safe domain which require improvement.

Our key findings were as follows:

  • A system was in place for staff to complete eLearning modules for essential training.

  • Discussions around training were now a standing item on the agenda at practice meetings to ensure learning became embedded.

  • Registration with the appropriate professional body was valid and in place for all relevant members of staff.

  • Two members of staff had not completed safeguarding training to the appropriate level.

  • There was no evidence that a member of staff conducting patient diabetes reviews had received appropriate training.

The areas where the provider must make improvements are:

  • Ensure staff receive training and support appropriate to their role.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

2 February 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Eldene Surgery on 2 February 2017.  Overall the practice is rated as requires improvement.

When we undertook a comprehensive inspection of Eldene Surgery in October 2014 we found breaches in the regulations relating to the safe delivery of services. When we did a follow up comprehensive inspection in January 2016 we found the previous breaches had been addressed although other areas of concern were found. The practice was rated as requires improvements because of concerns for the delivery of safe and responsive services. These full comprehensive reports can be found by selecting the ‘all reports’ link for Eldene Surgery on our website at www.cqc.org.uk.

Following the inspection in January 2016 the practice sent us an action plan setting out what they would do to meet the regulations.

This report covers the comprehensive inspection we carried out at Eldene Surgery on 2 February 2017 which was undertaken to check whether the practice had completed the actions they told us they would take to comply with regulations.

We found the practice had made improvements in the areas where we identified issues on our inspection in January 2016 but we found other areas of concern. Based on our findings the practice’s overall rating is requires improvement.

Our key findings were as follows:

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, the practice had not ensured appropriate checks had been carried out on staff employed by a subcontractor providing services which included visiting patients in their own homes.
  • The patients paper based records were not kept adequately secure.
  • Not all staff had received the essential training appropriate to their role such as safeguarding, mental capacity and infection control.
  • There was a lack of confidence in the management structure and staff told us they did not feel supported by the management structure. Staff did not always raise concerns and were not always taken seriously or treated with respect when they did.
  • Since the inspection in January 2016 the practice had carried out an assessment of the risk of legionella and was taking a range of actions to minimise the risks. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
  • Incidents were discussed in meetings initially to identify any learning or changes to practice and then reported to staff via staff meetings or other communication methods. The practice carried out an analysis of their significant events.
  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were in line with the national average.
  • The practice had worked with other local practices and the clinical commissioning group to develop an urgent care service to which patients wanting an on-the-day appointment could be seen if there was not capacity at the practice. This had helped reduce the pressure for appointments at the surgery which we noted at our inspection in January 2016.
  • Since our last inspection in January 2016 the practice had reviewed how it handled complaints. Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.
  • Not all appropriate emergency medicines were available on the day of our inspection.

Importantly, the provider must: 

  • Ensure all leaders have the necessary experience, knowledge, capacity and capability to lead effectively and to listen and respond appropriately to concerns raised by staff.
  • Ensure all staff receive the appropriate training required for them to carry out their role including safeguarding and infection control.
  • Ensure appropriate checks are carried out and recorded on third party suppliers.
  • Ensure the arrangements for data protection, including patients paper based records and third party employees based in the practice, meet the standards set out in the Data Protection Act 1998. 

In addition the provider should:      

  • Ensure recommendations from infection control audits are logged and appropriate action taken.
  • Ensure they have a system for checking that actions identified as a result of medicine alerts have been completed.
  • Ensure staff responsible for triaging appointment requests have the skills and expertise necessary to carry out this role.
  • Ensure they keep up to date records of staff training.
  • Ensure that computer screens are not visible to patients.
  • Review the ease with which patients can get through to the practice by phone. ​

Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall, it will be re-inspected within six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

19 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced follow up inspection at Eldene Surgery, Collingsmead, Swindon on 19th January 2016. We carried out this inspection to check that the practice was meeting the regulations and to consider whether sufficient improvements had been made. Our previous inspection in October 2014 found breaches in the regulations relating to the safe delivery of services. There were also concerns relating to the management and leadership of the practice affecting the safe and well led domains. At the inspection in January 2016 we found the pervious breaches had been addressed however other areas of concern were found. Overall the practice is rated as requires improvement.

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

  • There was an effective system in place for reporting and recording significant events.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations of verbal complaints were not thorough.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it difficult to make an appointment with a named GP and patients had to walk to the surgery when they could not get through on the telephone.
  • Urgent appointments were available on the day they were requested but patients were sometimes seen at a neighbouring medical practice with a different provider.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • Risks to patients were assessed and managed, with the exception of those relating to the premises, specifically in the management of legionella. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
  • The practice had sought feedback from patients and had an active patient participation group.

The areas where the provider must make improvements are:

  • Establish and operate an effective system to assess, manage and mitigate the risks identified relating to legionella.

  • Ensure the security of prescriptions within the premises

  • Improve the system for patient access to appointments and services.

In addition the provider should:

  • Review the processes for management of all complaints.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

22 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Eldene Surgery is a semi-rural teaching practice providing primary care services to patients resident in Fairford and the surrounding villages Monday to Friday. The practice has a patient population of just over 7,800 patients of which approximately 24% are over 65 years of age.

We undertook a scheduled, announced inspection on 22 October 2014. Our inspection team was led by a Care Quality Commission (CQC) Lead Inspector and GP specialist advisor. Additional inspection team members were a practice manager specialist advisor.

The overall rating for Eldene Surgery was requires improvement.

Our key findings were as follows:

  • Patients were able to get an appointment when they needed it.
  • The practice worked with the multidisciplinary team to support vulnerable patients and their families.
  • Carers were well supported.
  • Staff were caring and treated patients with kindness and respect.
  • Staff explained and involved patients in treatment decisions.
  • The practice had the appropriate equipment, medicines and procedures to manage foreseeable patient emergencies.
  • The practice managed repeat prescriptions efficiently and effectively.
  • The practice met nationally recognised quality standards for improving patient care and maintaining quality.
  • The practice delivered an insulin initiation service and worked in conjunction with a hospital consultant to monitor and support diabetic patients.
  • The regular review of the health and care needs of frail older adults to update care plans. The service included consultations and home visits on a Saturday.

However, there were also areas of practice where the provider needs to make improvements.

The provider must:

  • Ensure patient group directives are completed in line with national guidance.
  • Ensure there is a system to log the receipt and issue of prescription pads to GPs.
  • Operate a robust recruitment procedure which ensures the appropriate character, qualifications and security checks are undertaken, recorded and monitored.
  • Keep accurate staff training records to monitor staff have the appropriate qualifications, skills and knowledge to undertake their role.

The provider should:

  • Undertake practice risk assessments such as the control of substances hazardous to health and liquid nitrogen. Implement risk assessment action plans for example, recommendations of the legionella assessment.
  • Undertake regular clinical audit and complete clinical audit cycles.
  • Undertake an annual infection control audit
  • Ensure policies and procedures are up to date and accessible to staff
  • Develop a system to enable patient safety alerts to be disseminated to all relevant staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice