The Care Quality Commission
  • Doctor
  • GP practice

Archived: Jubilee Surgery

Overall: Good read more about inspection ratings

Barrys Meadow, High Street, Titchfield, Fareham, Hampshire, PO14 4EH (01329) 844220

Provided and run by:
Jubilee Surgery

All Inspections

14 December 2019

During an annual regulatory review

We reviewed the information available to us about Jubilee Surgery on 14 December 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

25 July 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 of Jubilee Surgery on 5 October 2016. The practice was rated as requiring improvement for providing safe and effective services; and was rated as good for providing caring, responsive and well-led services. As a result, the practice was given an overall rating of requires improvement. Following the comprehensive inspection we issued two requirement notices, due to a breach of the following Regulations:

  • Regulation 12 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to safe care and treatment;
  • Regulation 17 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to staffing.

Within our last inspection report we stated that the provider must:

  • Ensure all staff had received training in areas the practice considers are mandatory, including basic life support, safeguarding, information governance and fire safety to a level appropriate to their job role.
  • Ensure accurate records of training undertaken are maintained.
  • Ensure arrangements for monitoring of high risk medicines are safe and effective and patients received appropriate care and treatment.
  • Ensure there are suitable arrangements for monitoring prescription stationery.
  • Ensure appropriate actions are taken if the vaccine fridge temperatures were outside safe limits.

In addition, we stated that the provider should:

  • Review the arrangements for monitoring patients with a diagnosis of diabetes, to improve the exception reporting rate, and ensure appropriate care was given.
  • Review the arrangements for the recruitment of staff in order to demonstrate that all necessary checks had been completed prior to a member of staff commencing employment.
  • Review the safeguarding policies in order to reflect current organisations.
  • Review the systems in order to ensure clinical guidance was routinely audited and the practice are able to demonstrate that patients were receiving suitable treatment.
  • Review the arrangements in order to determine whether child defibrillator pads were needed.
  • Continue to identify patients who were also carers and the support provided.

The full comprehensive report on 5 October 2016 inspection can be found by selecting the ‘all reports’ link for Jubilee Surgery on our website at www.cqc.org.uk.

We undertook a focused follow-up inspection of the practice on 25 July 2017. The inspection was to confirm that the practice had implemented its action plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 5 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

There were key findings across all the areas we inspected during this follow-up inspection. We saw documentary and other evidence that:

  • All staff had received training in areas the practice considers are mandatory, including basic life support, safeguarding, information governance and fire safety to a level appropriate to their job role.
  • Accurate records of training undertaken were maintained.
  • An audit action plan regarding a blood test for patients had been implemented and ensured that arrangements for monitoring of high risk medicines were safe and effective, and patients received appropriate care and treatment.
  • The practice had suitable arrangements for security and monitoring of prescription stationery.
  • The practice had a record of appropriate actions taken if vaccine fridge temperatures were outside safe limits.
  • The practice had reviewed arrangements for monitoring patients with a diagnosis of diabetes, leading to an improved exception reporting rate, and ensuring that appropriate care was given.
  • Recruitment files had been updated and showed that all necessary checks had been completed prior to any new member of staff commencing employment.
  • Safeguarding policies were reviewed to reflect current contact information for external organisations who could be involved in any safeguarding issues.
  • Clinical guidance was followed and routinely audited and the practice was able to demonstrate that patients were receiving suitable treatment.
  • The practice had a risk assessment in place to determine whether child defibrillator pads were needed.
  • Continued to identify patients who were also carers and implemented the support they needed.

Following this inspection the practice was rated as good across all domains, which changed its overall rating to Good.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Jubilee Surgery on 5 October 2016. Overall the practice is rated as requires improvement.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and managed apart from those related to emergency equipment and high risk medicines.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. However, improvements were needed to ensure checks and audits of care and treatment were carried out routinely.
  • Staff were able to access training to provide them with the skills, knowledge and experience to deliver effective care and treatment. This was not consistent and records showed that there were gaps in training provision.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients 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.
  • Patients who were vulnerable were offered regular appointments with the same GP to support them.
  • The practice had a system in place to promote uptake in childhood vaccinations.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had produced pictorial guides on how to carry out tasks on the computer system, such as how to make an appointment or produce a repeat prescription. These had been shared with other practices in the area that used the same computer system.
  • 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 and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure all staff have received training in areas the practice considers are mandatory including basic life support, safeguarding information governance and fire safety to a level according to job role.
  • Ensure accurate records are maintained of training undertaken.
  • Ensure arrangements for monitoring of high risk medicines are safe and effective and patients receive appropriate care and treatment.
  • Ensure there are suitable arrangements for monitoring prescription stationery.
  • Ensure appropriate actions are taken if the medicine fridge temperatures are outside safe limits.

The areas where the provider should make improvement are:

  • Review arrangements for monitoring patients with diabetes, to improve the exception reporting rate, and make sure appropriate care is given.

  • Review arrangements for recruitment to demonstrate that all necessary checks have been completed prior to a member of staff commencing employment.

  • Review the safeguarding policies to reflect current organisations.

  • Review systems to ensure clinical guidance is routinely audited and the practice is able to demonstrate that patients are receiving suitable treatment.

  • Review arrangements for carrying out all clinical procedures to minimise risk of infection as far as practicably possible.

  • Review arrangements to determine whether child defibrillator pads are needed.

  • Continue to identify patients who are also carers and the support provided.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

15 May 2014

During an inspection looking at part of the service

During our inspection of 24 February 2014 we found that the provider had failed to carry out appropriate checks prior to staff commencing work at the practice. These checks are required to assure the provider that they have all the necessary information to ensure the staff they employ are suitable for their role and responsibilities.

The provider wrote and told us of the actions they would take to ensure that they carried out appropriate checks of their staff before they started work. We carried out this inspection to check that the practice had procedures in place to record the information required under Regulation 21 & Schedule 3 of the regulations of the Health and Social Care Act 2008. We found there were effective recruitment and selection processes in place, and appropriate checks were undertaken before staff began work.

24 February 2014

During a routine inspection

We spoke with six people who used the service, this included active members of the Patient Participation Group (PPG), and with clinical and non-clinical staff.

People we spoke with were generally positive about the service they received. All of the people we spoke with told us that the permanent staff were kind, respectful and polite. People said that during consultations the staff gave good explanations and they were able to ask questions if they needed to. People told us they felt involved and listened to.

People received care that ensured their safety and welfare. People's needs were assessed and care was provided to meet their individual needs. Diagnostic tests were carried out where required, referrals made if necessary and appropriately followed up.

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and respond appropriately.

Appropriate checks were not always carried out prior to staff starting work.

The practice monitored the quality of the service by performing audits and seeking the views of the patients by surveys and engagement in the Patient Participation Group (PPG). People we spoke with told us of the difficulties they had in gaining appointments. The practice had listened to this and were in the process of developing a new system of appointments to improve this for people.