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Inspection Summary

Overall summary & rating


Updated 2 November 2018

This practice is now rated as Good overall. (Previous rating November 2017 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

We carried out an announced comprehensive inspection at Mitcheldean Surgery on 30 November 2017. The practice was rated as good for providing effective, caring, responsive and well-led services giving an overall rating of good. However, the practice was rated as requires improvement for providing safe services. The full comprehensive report of the 30 November 2017 inspection can be found by selecting the ‘all reports’ link for Mitcheldean Surgery on our website at .

This inspection was an announced focused inspection carried out on 9 October 2018. The purpose of which was to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations identified in our previous inspection on 30 November 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe services. Overall the practice remains rated as good.

At this inspection we found:

  • The infection prevention control (IPC) lead nurse had completed a training update and had received additional training to undertake this role.
  • Systems to ensure test results and correspondence were managed appropriately had been reviewed and improved so that they were dealt with in a timely manner.
  • Systems for managing healthcare waste had improved.
  • Appropriate measures had been put in place to ensure the safe management of liquid nitrogen in the practice.
  • Systems had been reviewed and improvements implemented to ensure the security of blanks prescription forms were maintained in the practice.
  • Risks associated with lone working in the dispensary had been assessed and measures put in place to minimise risks.
  • Systems had been introduced to ensure medicines in the dispensary were managed correctly and that medicines were in date.
  • The practice routinely invited carer’s for a health check. We saw the number of carers who had been invited and received a health check had increased since the last inspection.

The areas where the provider should make improvements are:

  • Continue to identify and improve the number of patients identified as carers.

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.

Inspection areas



Updated 2 November 2018

We rated the practice as requires improvement for providing a safe service at the last inspection on 30 November 2017. We found gaps in systems to monitor, manage and mitigate risks for:

  • Infection prevention and control.
  • Security of blank prescriptions.
  • The processing of test results.
  • The storage of liquid nitrogen.

We also told the practice that they should:

  • Review systems and processes across all aspects of care so that governance is consistently effective.
  • Assess risks in relation to lone working in the dispensary.
  • Review systems in place to ensure medicines were managed correctly and were in date.
  • Invite carers for a health check.

The practice produced an action plan outlining the improvements it would make to address the shortfalls.

These arrangements had significantly improved when we undertook a follow up inspection on 9 October 2018. The practice is now rated good for providing safe services.

Safety systems and processes

The practice had clear systems to keep people safe and safeguarded from abuse.

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Learning from safeguarding incidents were available to staff. Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (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.)
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, discrimination and breaches of their dignity and respect.
  • Systems to ensure the timely and appropriate management of test results and correspondence had been improved. There was a “buddy system” implemented where each GP covered a colleague during absences. Additionally, there was a system whereby results were automatically allocated to the GP’s buddy for checking and processing.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control. The infection prevention control (IPC) lead nurse had completed update training and had received additional training to undertake this role. The IPC policy had been reviewed in January 2018 and a full audit was undertaken in September 2018.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe. We observed clinical waste was labelled with the practice identifier to ensure that waste was traceable back to its source as required by the safe management of healthcare waste regulations. The practice had also taken the initiative to inform all the practices in the locality so that they can implement action if this was not being adhered to.

Risks to patients

There were adequate systems to assess, monitor and manage risks to patient safety.

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • There was an effective induction system for temporary staff tailored to their role.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

The practice had reliable systems for appropriate and safe handling of medicines.

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • The storage and handling of liquid nitrogen used in the practice had been reviewed. The container was stored securely. Cold insulating gloves and eye protection was available and a padlock had been fitted to the cylinder so that this could not be tampered with.
  • Staff prescribed and administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance.
  • The practice logged and monitored prescription stationery use. Systems and processes had improved to ensure these were secure when placed in printers in consulting rooms. Locks had been fitted to each consulting and treatment rooms. A system had been introduced where prescriptions were removed from all rooms at the end of the day and stored securely.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.
  • Arrangements for dispensing medicines at the practice kept patients safe.
  • Systems had been introduced to ensure medicines held in stock in the dispensary were managed correctly and in date. The practice carried out three monthly stock check where expiry dates were also checked. These were also recorded.
  • Risks in relation to lone working in the dispensary had been assessed and measures put in place to minimise those risk. For example, medicines at higher risks were checked twice a day.

Track record on safety

The practice had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed safety using information from a range of sources.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.

The practice had improved the way it supported carers. Patients identified as carers were routinely invited for a health check. Practice data showed that 42 patients were registered as carers. Out of those, 19 had received a health check. The practice had reviewed the number of patients who were still carers and identified out of 200 patients, 42 were currently carers. Information was available in the waiting area so patient could identify themselves as carers. There was a dedicated reception staff who would actively asked patient if they were also a carer.

The practice had implemented improvements at systems level to ensure those were consistently effective.

Please refer to the evidence tables for further information.








Checks on specific services

People with long term conditions


Updated 23 January 2018

Families, children and young people


Updated 23 January 2018

Older people


Updated 23 January 2018

Working age people (including those recently retired and students)


Updated 23 January 2018

People experiencing poor mental health (including people with dementia)


Updated 23 January 2018

People whose circumstances may make them vulnerable


Updated 23 January 2018