The Care Quality Commission
  • Doctor
  • GP practice

The Friary Surgery

Overall: Good read more about inspection ratings

Queens Road, Richmond, North Yorkshire, DL10 4UJ (01748) 822306

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

17 January 2020

During an annual regulatory review

We reviewed the information available to us about The Friary Surgery on 17 January 2020. 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.

25/10/2018

During a routine inspection

This practice is rated as Good overall. (Previous rating 7 February 2017– Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at The Friary Surgery on 25 October 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had clear 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.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Review the immunisation of healthcare staff.
  • Introduce annual infection control audits.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

7 February 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at The Friary Surgery on 23 June 2016. Overall the rating for the practice was inadequate (safe and well-led inadequate, effective, caring and responsive as requires improvement) and was placed in special measures for a period of six months.

In particular, on 23 June 2016, we found the following areas of concern:

  • There was an ineffective system in place for reporting and recording significant events. There was limited evidence to show that significant events and complaints were reviewed and thoroughly investigated to prevent further occurrences and secure improvements.
  • When things went wrong, lessons learned were not communicated widely enough to support improvement. There was no evidence of any improvement action plans.
  • Patients were at risk of harm because the systems and processes in place were ineffective. We found concerns in relation to health and safety, management of safeguarding, recruitment of staff, medicines management, infection control, safe storage of patient records and the ability to respond to clinical and non-clinical emergencies.
  • The outcomes of patients’ care and treatment were not always monitored regularly.
  • Clinical audits were not routinely carried out to improve care, treatment and people’s outcomes.
  • The practice could not demonstrate how they ensured oversight of role-specific training and updating for relevant staff. Staff received some training but we identified staff that had not completed training in a range of areas that included safeguarding adults, fire safety awareness, basic life support, infection control and information governance.
  • Whilst complaints were responded to lessons learned and action taken was not sufficiently detailed to assure lessons had been learnt. Complaints were not monitored over time to enable the practice to look for trends and areas of risk that may be addressed.
  • The practice did not have an overarching governance framework which supported the delivery of good quality care. No formal meetings between staff took place. We were told any issues were discussed at daily coffee breaks. None of these meetings were recorded.

As a result of our findings at this inspection we took enforcement action against the provider and issued them with a warning notice for improvement.

Following the inspection on 23 June 2016 the practice sent us an action plan that explained what actions they would take to meet the regulations in relation to the breaches of regulations and the warning notices that we issued.

We carried out a further comprehensive inspection at The Friary Surgery on 7 February 2017 to check whether the practice had made the required improvements. We found that all improvements had been made.

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 well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • On all but a small number of comments cards received, 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.
  • The practice was equipped to treat patients and meet their needs. Some areas of the practice required maintenance and redecoration.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice had significantly improved their governance framework. For example a structure of meetings, audits and completion of training had been put in place which provided an overarching governance framework which supported the delivery of the strategy and good quality care.
  • The partners and new practice manager supported by staff demonstrated they had taken on board all the issues we identified at the previous inspection and had committed the practice to deliver improvement.
  • The practice demonstrated a commitment to ensuring that the significant changes and improvement the practice had made would be monitored and embedded into future practice to ensure the improvement made was sustained.

The areas where the provider should make improvement are:

  • Consider the arrangements for maintaining/redecorating the practice to ensure infection control risks are minimised particularly in treatment rooms.
  • Formalise the arrangements for managing test results.
  • Review the arrangements in respect of the practices implementation of the Accessible Information Standard.
  • Review the system that identifies patients who are also carers to help ensure that all patients on the practice list who are carers are offered relevant support if appropriate.
  • Ensure the improvement made is monitored and embedded into practice to ensure sustainability over time.

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

23 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Friary Surgery on 23 June 2016. Overall the practice is rated as inadequate.

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

  • Patients were at risk of harm because the systems and processes in place were ineffective. We found concerns in relation to health and safety, management of safeguarding, recruitment of staff, medicines management, infection control and the ability to respond to clinical and non-clinical emergencies.
  • Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, when things went wrong, lessons learned were not communicated widely enough to support improvement. There was no evidence of any improvement action plans.
  • The practice kept up to date with relevant and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • The outcomes of patients’ care and treatment were not always monitored regularly. Clinical audits were not routinely carried out to improve care, treatment and people’s outcomes.
  • Clinical and non-clinical staff had not received all of the training necessary to carry out their roles effectively.
  • 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. Whilst complaints were responded to lessons learned and action taken was not sufficiently detailed to assure lessons had been learnt. Complaints were not monitored over time to enable the practice to look for trends and areas of risk that may be addressed.
  • Patients said they were able to get an appointment with a GP when they needed one, with urgent appointments available the same day.
  • The practice did not have an overarching governance framework which supported the delivery of good quality care.
  • The practice had no clear leadership structure and insufficient leadership capacity.

The areas where the provider must make improvement are:

  • Ensure that incidents that may affect the health, safety and welfare of people using services, such as significant events or a complaint is recorded, reviewed and thoroughly investigated to prevent further occurrences.

  • Ensure the proper and safe management of medicines.

  • Ensure there are adequate systems in place for assessing the risk of, preventing, detecting and controlling the spread of infections, including those that are health care associated.

  • Ensure recruitment arrangements include all necessary pre-employment checks for all staff.

  • Ensure patient records are securely maintained.

  • Carry out clinical audits including re-audits to ensure improvements have been achieved and that guidance is being followed.

  • Ensure staff receive appropriate support, including appraisal and training relevant to their role.

  • Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which is reflective of the requirements of the practice.

  • Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements.

  • Ensure an overarching governance framework which supports the delivery of good quality care is put in place.

  • Ensure risks and issues are always identified and dealt with appropriately and in a timely way.

The areas where the provider should make improvement is:

  • Ensure action is taken to proactively identify carers registered at the practice.

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

5 September 2013

During a routine inspection

During the inspection of this practice, we spoke with patients, one doctor who worked at the practice, the practice manager, a practice nurse and reception staff.

We talked to some patients and asked about their experiences when visiting the practice. They told us they were satisfied with the care, support and advice they had received. One patient said 'All the staff are very helpful and kind, nothing is too much trouble. The reception staff are very good "

We observed the experiences of patients who used the service. We saw that staff interacted and communicated well with people. When we looked around the practice we found that it was clean and tidy.

We found that patients were safeguarded against the risk of abuse.

We saw that effective systems were in place to deal with any complaints made about the practice.

The practice was compliant in all of the outcome areas we looked at during this inspection.