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Inspection carried out on 28 March 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 Kingsholm Surgery on 7 November 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Kingsholm Surgery on our website at

This inspection was a desk-based review carried out on 28 March 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 in our previous inspection on 7 November 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

Our key findings were as follows:

  • The practice had reviewed and updated their fire procedures. A fire risk assessment and subsequent actions and recommendations had been carried out.

  • The practice had reviewed and updated their procedures for checking and maintaining emergency equipment, and medicines, and had implemented a log to check these regularly.

  • The practice had reviewed their Disclosure and Barring Service (DBS) procedure to ensure that all staff who undertook chaperoning duties had received a DBS check. (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 practice had updated their training matrix to ensure that all outstanding training had been undertaken by all staff.

  • All staff that had been in post for a minimum of 12 months had received an annual appraisal.

During our previous inspection we also highlighted areas where the practice should consider improvement and these had improved as follows:

  • The practice had ensured that safety alerts were logged with actions taken recorded.

  • The practice continued to monitor and improve outcomes for patients with long term conditions.

  • The practice was improving their identification of carers.

  • The practice had established a patient participation group for engaging with their patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 7 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kingsholm Surgery on 7 November 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. However, safety alerts were disseminated to relevant staff members but there was no system in place to log and record any actions taken.

  • The practice did not have an up to date completed fire risk assessment, no fire drills had been undertaken and fire procedures were not displayed in patient areas. There was no log in place to check emergency medicines and equipment; we found that one of the two oxygen cylinders was empty.

  • 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. However, we found that staff had not completed the following mandatory training: infection control and fire safety. Staff members’ appraisals had lapsed and had not been completed for two years.

  • 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.

  • The practice provided patient access to urgent appointments which were scheduled for the same day and routine appointment could be scheduled within one week.

  • 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 and complied with the requirements of the duty of candour.

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

Importantly, the provider must:

  • Complete a fire risk assessment, detailing and undertaking any relevant actions as required, fire drills must be undertaken at the frequency identified within the fire risk assessment. Fire procedures must also be visible for patients.

  • The practice must complete a risk assessment for non-clinical staff who act as chaperones but do not have a Disclosure and Barring Service (DBS) check.

  • Establish and operate an effective system to check, manage and mitigate the risks associated with the emergency equipment and medicines.

  • The provider must implement and undertake appraisals for all staff and ensure all mandatory training including infection control and fire safety is completed by all staff.

In addition the provider should:

  • Ensure that safety alerts are logged with actions taken recorded and discussed at relevant staff meetings.

  • Continue to monitor and improve outcomes for patients with long term conditions.

  • Improve their identification of carers.

  • Establish patient participation engagement within the practice to ensure feedback is proactively sought.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 16 January 2014

During a routine inspection

One GP partner had left and one had joined the surgery but the information had not been shared with CQC. The provider has now submitted the registration applications.

Patients felt supported and involved in their care. One patient said �they give me enough time and information to make decisions�. The practice was sensitive to people�s privacy and dignity. One person told us �staff are really friendly but stay professional�. Patients felt they received high quality care. One person told us staff were always �completely thorough and professional�. People also found it easy to book an appointment and one person told us �it�s extremely easy to book�.

There were safeguarding policies in place supported by staff training which meant staff felt able to raise concerns. There was a good understanding of the Mental Capacity Act 2005 but there was scope for additional training.

The building was well maintained and clean. There were no access problems for people with a disability although there was no convenient parking. Safety checks were completed but there was no business continuity plan in place.

The practice scored well in the national satisfaction survey. Seventy three per cent of patients would recommend the surgery to a friend compared with 48% nationally. Patients we spoke with felt no improvements were needed. Complaints and incidents were used as a learning opportunity. There was a lack of information on complaints for patients and currently no patient group.