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Inspection carried out on 6 February 2020

During an inspection to make sure that the improvements required had been made

We carried out an announced comprehensive inspection at Wycliffe Surgery on 6 February 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 including information provided by the practice. Our review indicated that there may have been a significant change (either deterioration or improvement) to the quality of care provided since the last inspection in April 2016.

This inspection focused on the following key questions:

  • Are services effective?
  • Are services well led?

Because of the assurance received from our review of information, we carried forward the ratings for the following key questions:

  • Are services safe? (Good)
  • Are services caring? (Good)
  • Are services responsive? (Good)

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

We provided the practice with Care Quality Commission feedback cards prior to the inspection and we received 19 completed cards. Patients were extremely positive about the practice staff, their experiences, and the care and treatment they received.

We have rated this practice as good overall; good for providing effective and well led services; requires improvement for the population group containing working age people (including those recently retired and students) and good for all other population groups because:

  • The practice had successfully coped with a 2,500 patient increase in their list size due to the very recent closure of a local practice
  • 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.
  • Staff 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.
  • The practice had a culture that drove high quality sustainable care.
  • 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.

Although we did not find any beaches of regulation on this inspection, we did see one area where the provider should make improvements. These are:

  • Continue to improve arrangements to increase the uptake of cervical screening.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 4 October 2016

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We carried out an inspection of Wycliffe Surgery on 4 October 2016. This review was performed to check on the progress of actions taken following an inspection we made in April 2016. Following the inspection in April 2016 the provider sent us an action plan which detailed the steps they would take to meet their breach of regulation. During our latest inspection on 4 October 2016 we found the provider had made the necessary improvements.

This report covers our findings in relation to the requirements and should be read in conjunction with the report published in January 2015. This can be done by selecting the 'all reports' link for Wycliffe Surgery on our website at www.cqc.org.uk

Our key findings at this inspection were as follows:

The practice had improved the governance systems to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. This included the introduction of improved:

  • Systems to manage and monitor infection control procedures, including infection control audits, disposal of water used to wash leg ulcers and booking infection control training.
  • Processes to monitor and keep an overview of significant events and complaints.
  • Assessment of the risk of non-clinical staff generating prescriptions following changes in medicines for patients discharged from hospital.
  • Systems to evidence that all nurses were currently on the Nursing and Midwifery Council register
  • Monitoring to ensure all staff received annual appraisals.

The provider had also implemented changes to identify and support more carers within the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 13 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Wycliffe Surgery on Wednesday 13 April 2016. The practice was rated as requires improvement for well led but overall the practice is rated as good.

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, managing and recording serious significant events. The focus at the practice was on more serious events which were managed by the GPs. Evidence was not provided to show what learning had taken place following less serious events.
  • Risks to patients were assessed and well managed with the exception of prevention of infection control and management of medicines.
  • 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.
  • 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, although an overview of the process to monitor and record outcomes for less serious and verbal complaints was not available.
  • 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 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.

The areas where the provider must make improvement are:

To Introduce systems and processes to assess, monitor and improve the quality and safety of the services provided and assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. For example;

  • Arrangements to risk assess and manage infection control processes and systems.

  • Systems to maintain an overview of significant events and complaints to show what action had been taken to identify and monitor trends.

  • Assess the risk of non-clinical staff generating prescriptions following changes in medicines for patients discharged from hospital.

  • Systems to ensure evidence is obtained to show nurses are currently on the Nursing and Midwifery Council register.

  • Systems to ensure that all staff had an appraisal each year.

The areas where the provider should make improvement are:

  • Investigate ways of improving the number of carers identified and provide appropriate support for them.

  • Ensure infection control audits are performed in line with current practice guidelines.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice