The Care Quality Commission
  • Doctor
  • GP practice

Southmead Surgery

Overall: Good read more about inspection ratings

Blackpond Lane, Farnham Common, Slough, Buckinghamshire, SL2 3ER (01753) 643195

Provided and run by:
Southmead 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 Southmead 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 Southmead Surgery, you can give feedback on this service.

14 Jan 2020

During an inspection looking at part of the service

We carried out an announced focused inspection at Southmead Surgery, a GP practice in Farnham Common, South Buckinghamshire on 14 January 2020 as part of our inspection programme.

We carried out an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:

  • Are services effective?
  • Are services well-led?

Following assurance received from our review of information we carried forward the ratings for the following key questions from the previous inspection in March 2017:

  • Are services safe?
  • Are services caring?
  • Are services responsive?

We based our judgement of the quality of care at this service on a combination of:

  • What we found when we inspected

  • Information from our ongoing monitoring of data about services

  • Information from the provider, patients, the public and other organisations.

We have rated this practice as good overall. We rated the practice as good for providing effective and well-led services and for the following population groups: older people; people with long term conditions, families children and young people; working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including dementia).

We found that:

  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.

  • The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.

  • Staff had the skills, knowledge and experience to deliver effective care, support and treatment.
  • The practice worked together and with other organisations to deliver effective care and treatment.

  • There was compassionate, inclusive and effective leadership at all levels. This included working with and supporting the practice Patient Participation group (PPG).

  • The practice had a clear vision and set of values that prioritised quality and sustainability.

  • There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • There were clear and effective processes for managing risks, issues and performance.

We saw an area of outstanding practice:

  • The practice provided an outstanding service to patients with caring responsibilities. This service was recognised by Carers Bucks (an independent charity to support unpaid, family carers in Buckinghamshire) and the practice was awarded an Investors in Carers GP Standard award. This was in recognition of the extra support they offer to unpaid carers who were registered at the practice. The practice had also engaged with the local boy’s prep school who accessed GP services from the practice and a local older person’s charity to create a buddy and pen pal initiative between the school and older people (including those with caring responsibilities) within the practice. This initiative was created to reduce loneliness, social isolation and also to increase engagement and community within the village.

Whilst we found no breaches of regulations, the provider should:

  • Continue to improve uptake for cervical screening to ensure the practice’s meets the national target of 80%.

Details of our findings and the evidence supporting the change in rating are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

13 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Southmead Surgery on 14 July 2016. The practice was rated inadequate and the practice was placed in special measures for a period of six months. Specifically, the practice was rated inadequate for the provision of safe and well-led services. The practice was rated requires improvement for responsive services and good for effective and caring services. We asked the practice to tell us what action they would take to address the breach of regulation found at inspection. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Southmead Surgery on our website at www.cqc.org.uk.

This inspection, on 13 March 2017, was a comprehensive inspection undertaken to check the actions taken had addressed the breach of regulation and to apply an updated rating for the practice.

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

  • We found evidence that improvements had been made. The practice had implemented new systems and processes to evidence these improvements. Our improved rating of good reflects the positive development of leadership and management systems to deliver significant progress in improving services across the board for all patient groups.
  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Staff had been trained with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with 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.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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 the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
  • Southmead Surgery has made significant improvements following the last inspection. The practice should continue to sustain these and ensure further continuous improvements are identified through their governance processes.

The areas where the provider should make improvement are:

  • Review the monitoring system of blank prescription stationary to ensure that prescription use is monitored more effectively.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

14 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Southmead Surgery on 14 July 2016. Overall the practice is rated as inadequate.

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

  • Risks to patients were inconsistently assessed and managed, including those relating to building safety checks, triage of patients attending the walk in clinic, a tool used to assess same day appointments was inappropriate and ensuring safety alerts were actioned and recorded.
  • Opportunities were missed to learn from complaints as verbal complaints were not logged or shared with the staff.
  • There was no evidence that learning from significant events and complaints were fully shared with all staff. There was a new system in place to log there incidents, however the was no reassurance that this system was embedded and effective within the practice.
  • Emergency procedures were not robust in relation to assessment of medicines required during home visits and for emergency medicines available at the practice.
  • Although emergency medicines were always available in the practice, when GPs took the emergency kit with them on home visits the emergency medicines were not easily available. This could impede the ability to respond quickly.
  • Patients said they were treated with compassion, dignity and respect.
  • Data showed patient outcomes were comparable to the national average and there was a comprehensive audit system in place that was used to drive improvements in patient outcomes, including designing new clinical pathways.
  • Information about services was available in a format to enable everybody to understand and access it.
  • The practice had a number of policies and procedures to govern activity, but not all were followed. For example, out of date needles and syringes were found in the emergency kit, and a chaperone was used without training or a Disclosure and Barring Service (DBS) check in place (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

The areas where the provider must make improvements are:

  • Review the appropriateness of clinical triage and patient access to appointments to ensure systems are safe and that staff are suitably trained to implement these systems.
  • Have effective communication systems in place to ensure that all relevant staff knows the results and actions required following reviews into significant events and complaints.
  • Ensure all staff that chaperone have a Disclosure and Barring Service (DBS) check in place and appropriate training before commencing chaperoning.
  • Ensure all complaints whether written or verbal are documented to identify trends and learning to mitigate the risks identified to people who use the service and that findings shared with all relevant staff.
  • Ensure an appropriate risk assessment is undertaken to identify what medicines are needed for use during home visits.
  • Ensure safety alerts are actioned and recorded and appropriate records are maintained to mitigate risks to service users.
  • Ensure the premise used by the practice is safe for their intended purpose. Specifically, gas safety and fixed electrical safety checks.
  • Review the arrangements to monitor and maintain emergency medicines and equipment to ensure appropriate action can be taken if there is a clinical or medical emergency.
  • Monitor the distribution of blank prescription stationery within the practice in accordance with current guidelines.

In addition the provider should:

  • Ensure patients continue to be given the opportunity to be part of the patient participation group (PPG) to enable the patient’s voice to be heard.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice