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Inspection carried out on 14 February 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Upton Village Surgery on 21 June 2016. The overall rating for the practice was Good. However, the practice was rated as Requires Improvement for providing safe services. The full comprehensive report on the June 2016 inspection can be found by selecting the ‘all reports’ link for Upton Village Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 14 February 2017 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 at our previous inspection on 21 June 2016. This report covers our findings in relation to those requirements, additional improvements made since our last inspection and further improvements that should be made.

Overall the practice is rated as Good.

Our key findings were as follows:

  • Action had been taken to ensure that a record of the required staff recruitment information was maintained.

The following improvements to the service had also been made:

  • A system had been introduced to ensure a record was made of the receipt and allocation of printable prescriptions.

  • A review of the system for monitoring staff training needs had taken place.

  • The complaint procedure had been revised to reflect the alternative complaint pathways advertised on the practice website.

We identified an area of practice where the provider should make improvements:

  • The provider should ensure that the training plan is followed so that staff receive the training they require for their roles.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 21st June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Upton Village Surgery on 21 June 2016.

Overall the practice is rated as good.

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

  • There were systems in place to reduce risks to patient safety, for example, infection control procedures, medication management and the management of staffing levels. Improvements were needed to the records of recruitment to demonstrate the suitability of staff employed. Improvements should be made to the management of printable prescriptions.

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Staff were aware of procedures for safeguarding patients from the risk of abuse.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.

  • Staff felt well supported. They told us they had received training appropriate to their roles. The records of all staff training needed to be improved to assist in monitoring and planning for the training needs of staff.

  • Patients were positive about the care and treatment they received from the practice. The National Patient Survey January 2016 showed that patients’ responses about whether they were treated with respect, compassion and involved in decisions about their care and treatment were comparable to local and national averages.

  • Services were planned and delivered to take into account the needs of different patient groups.

  • The National GP Patient Survey results showed that patient’s satisfaction with access to care and treatment was generally in line with local and national averages.

  • Information about how to complain was available. There was a system in place to manage complaints.

  • There were systems in place to monitor and improve quality and identify risk.

However there were areas of practice where the provider must make improvements:

  • The provider must ensure that there is a record of the required recruitment information to confirm the suitability of staff employed.

The areas where the provider should make improvements are:

  • A record should be made of the receipt and allocation of printable prescriptions.

  • Review the system of identifying staff training requirements to assist in monitoring and planning for the training needs of staff.

  • The complaint procedure at the practice should be improved to reflect the alternative complaint pathways advertised on the practice website.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 4 June 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Upton Village Surgery on 21 June 2016. The overall rating for the practice was Good. However, the practice was rated as Requires Improvement for providing safe services. The full comprehensive report on the June 2016 inspection can be found by selecting the ‘all reports’ link for Upton Village Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 14 February 2017 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 at our previous inspection on 21 June 2016. This report covers our findings in relation to those requirements, additional improvements made since our last inspection and further improvements that should be made.

Overall the practice is rated as Good.

Our key findings were as follows:

  • Action had been taken to ensure that a record of the required staff recruitment information was maintained.

The following improvements to the service had also been made:

  • A system had been introduced to ensure a record was made of the receipt and allocation of printable prescriptions.

  • A review of the system for monitoring staff training needs had taken place.

  • The complaint procedure had been revised to reflect the alternative complaint pathways advertised on the practice website.

We identified an area of practice where the provider should make improvements:

  • The provider should ensure that the training plan is followed so that staff receive the training they require for their roles.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

CQC Insight

These reports bring together existing national data from a range of indicators that allow us to identify and monitor changes in the quality of care outside of our inspections. The data within the reports do not constitute a judgement on performance, but inform our inspection teams. Our judgements on quality and safety continue to come only after inspection and we will not make judgements on data alone. The evidence tables published alongside our inspection reports from April 2018 onwards replace the information contained in these files.