The Care Quality Commission
  • Doctor
  • GP practice

Mitcheldean Surgery

Overall: Good read more about inspection ratings

Brook Street, Mitcheldean, Gloucestershire, GL17 0AU (01594) 542270

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

2 April 2020

During an annual regulatory review

We reviewed the information available to us about Mitcheldean Surgery on 2 April 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.

09 Oct to 09 Oct 2018

During an inspection looking at part of the service

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.

30 November 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Mitcheldean Surgery on 30 November 2017 as part of our inspection programme.

At this inspection we found:

  • The practice had systems to manage risk so that safety incidents were less likely to happen. However these did not always operate effectively. For example in relation to infection prevention control, security of blank prescriptions and ensuring that test results and incoming letters were actioned when a GP was absent from the practice.
  • 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. The practice was above average for its satisfaction scores on consultations with GPs and nurses in a number of areas.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it. In order to further improve this, the practice had recently developed and implemented an access hub with10 other practices in the area to improve patient access to primary care services.
  • There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Review systems and processes across all aspects of care so that governance is consistently effective.
  • Lone working within the dispensary should be risk assessed.
  • Systems to ensure medicines are correctly managed and in date should be reviewed.
  • Carers should be invited for health checks.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 August 2015

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We last carried out a comprehensive inspection of Mitcheldean Surgery on 14 January 2015. At that inspection the practice was found to be requiring improvement for medicines management which falls within the safe domain. The report was published on 11 June 2015. This inspection undertaken on 5 August 2015 was specifically to follow up on the findings from our last inspection in January 2015.

Action had been taken by the provider and we found the practice was now meeting the relevant regulations and was now rated as good for medicines management with the overall rating for the safe domain being good. All population groups remained good, the same as at the previous inspection.

Our key findings were as follows:

  • There were arrangements in place to deal with medical emergencies appropriately and changes had been made to ensure emergency medicines were held securely and monitored at regular intervals this included equipment used in an emergency.
  • There were arrangements in place to ensure that the potential risk of spread of infection was reduced through management of infection control. This included the completion of regular infection control audits.

We saw one area of outstanding practice including:

  • The practice was proactive in understanding the need of patients with a learning disability and delivered their care in a way that met their needs and promoted equality. For example, they had increased accessibility to the practice to meet patient’s individual needs, such as patients having the first appointment of the day and the practice accommodated patients to wait where they wished and felt most comfortable. To increase patient’s involvement and understanding in their treatment decisions the practice had produced easy read guidance for patients on cervical smears and smoking cessation. Feedback from learning disability homes within the local area was very positive about the practice ‘can do’ attitude, especially in seeing patients at home promptly. Some patients had moved to this practice following recommendations from others using the service. Patients felt comfortable within the practice environment and had used the practice facilities for some time to hold local support group meetings for patients with a diagnosis of Asperger’s syndrome.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

14 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mitcheldean Surgery on Wednesday 14 January 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. They were also good for providing services for the all the population groups and had an outstanding element for how they treated patients with a learning disability. They required improvement for providing safe services particularly for the management of medicines.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed, with the exception of those relating to the management of medicines and infection control.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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.
  • 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.

We saw one area of outstanding practice:

  • The practice was proactive in understanding the needs of patients with a learning disability and delivered their care in a way that met their needs and promoted equality. For example, they had increased accessibility to the practice to meet patient’s individual needs, such as patients having the first appointment of the day and the ability to wait outside the practice for their appointment, if they wanted. To increase patient’s involvement and understanding in their treatment decisions the practice had produced easy read guidance for patients on cervical smears and smoking cessation. Feedback from learning disabilities homes was very positive about the practice ‘can do’ attitude in seeing patients at home promptly. Some residents had moved to this practice following recommendations from others using the service. Patients and others feel comfortable within the practice environment and used the practice facilities for some time to hold local Asperger’s support group meetings.

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

Importantly the provider must;

  • Ensure medicine management systems are reviewed to ensure all medicines are kept securely and monitored appropriately.

And the provider should;

  • Ensure emergency equipment checks are recorded to ensure equipment is maintained and checked at the correct intervals.
  • Ensure infection control audits were completed at appropriate timescales to ensure the practice followed adequate infection control procedures to keep patients safe from the risk of infection.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice