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Inspection carried out on 13 Mar

During an inspection looking at part of the service

This practice is rated as Good overall and in the safe domain. (Previously inspected December 2017 where it was rated as good overall and requires improvement in safe)

From the inspection in December 2017 the practice was told they must:

  • Safe care and treatment must be provided in a safe way to patients, including the proper and safe management of medicines and acting on all medicine alerts.
  • Review their significant event reporting and investigation process following incidents that affect the health, safety and welfare of people using the service.
  • Review their process in managing the use of prescription forms throughout the practice so as to mitigate risk.

The full comprehensive report can be found by selecting the ‘all reports’ link for The Fairlands Practice on our website at www.cqc.org.uk.

This inspection was an announced follow up inspection carried out on 13 March 2019, 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 December 2017. This report covers our findings in relation to those improvements made since our last inspection.

Our judgement of the quality of care at this service is based 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.

The practice is rated as good overall and good for all the population groups.

The key question is now rated as:

Are services safe? – Good

At this inspection we found: -

  • There was a system for the tracking of prescription stationery throughout the practice.
  • We checked the emergency response bag and found all medicines were within their expiry date. There was a recorded monthly check carried out by the nurses.
  • Any errors in dispensing medicines were recorded and investigated.
  • The dispensary had processes for collecting near-miss error data.
  • Dispensary staff showed us standard operating procedures which covered all aspects of the dispensing process (written instructions about how to safely dispense medicines). We saw evidence of regular review of these procedures.
  • The controlled drug register was correctly completed and there was evidence to demonstrate that expiry dates and balance checks of medicines were being undertaken.
  • Significant events were recognised and recorded as such.
  • The dispensary team were informed of medicine alerts and acted appropriately, which included having their own folder to retain alerts and recording action taken. This was detailed in the standard operating procedures.

The areas where the provider should make improvements are:

  • Review how the practice could provide information in accessible formats.
  • Review other avenues of learning to support the dispensary staff with their development.

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 5 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection October 2014– Good)

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 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 inspection at The Fairlands Practice on 5 December 2017. The inspection was carried out as part of our inspection programme.

At this inspection we found:

  • Staff were motivated and inspired to offer kind and compassionate care and respected the totality of their needs.

  • The patient participation group was also active. The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group (PPG). For example, the practice provided appointments on a Saturday morning.

  • Access to interpreters was available, including British Sign Language, for patients who required this help.

  • The practice ensured that appropriate patients, those deemed to be at risk or especially frail, received a proactive anticipatory care plan in partnership with the patient and any carer.

  • The practice was proactive in undertaking clinical audit to improve patient care.

  • The practice had an effective infection control process in place and acted on issues found during audits.

  • The practice ensured all recruitment checks were undertaken prior to staff starting employment.

  • A GP undertook a weekly ward round at a local nursing home to promote continuity of care.

  • The practice was trialling an electronic consultation system which enabled patients to contact a doctor and obtain a response within two working days.

  • A member of staff acted as a carers’ champion to help ensure that the various services supporting carers were coordinated and effective.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Safe care and treatment must be provided in a safe way to patients, including the proper and safe management of medicines and acting on all medicine alerts.

  • Review their significant event reporting and investigation process following incidents that affect the health, safety and welfare of people using the service.

  • Review their process in managing the use of prescription forms throughout the practice so as to mitigate risk.

The areas where the provider should make improvements are:

  • To ensure all staff receive appropriate training commensurate to their role.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 31 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Fairlands Practice on 31 October 2014. Overall the practice is rated as good.

Specifically, we found the practice good for providing safe, effective, caring, responsive services and being well led. It was also good for providing services for the all the population groups.

We visited the practice location at Fairlands Medical Centre, Fairlands Avenue, Worplesdon, Guildford, GU3 3NA. The Fairlands Practice also operates a branch surgery at Glaziers Lane Surgery, Glaziers Lane, Normandy, Guildford, Surrey, GU3 2DD. We did not visit the branch surgery as part of our inspection.

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.
  • 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 relatively easy to make an appointment with a named GP and that 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 areas where the provider should make improvement are:

  • Ensure that the lock on the refrigerator is fixed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice