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Review carried out on 14 August 2019

During an annual regulatory review

We reviewed the information available to us about Eden Surgery on 14 August 2019. 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.

Inspection carried out on 8 December 2015

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 announced comprehensive inspection of Eden Surgery on 26 January 2015. We found that effective recruitment procedures were not in place and the governance systems in place were not operating effectively in respect of ensuring risks were mitigated against in respect of infection control, health and safety, medicines management and using feedback to continually improve services.

We carried out an announced focussed inspection at Eden Surgery on 8 December 2015 to check that improvements had been made to meet the legal requirement following our

comprehensive inspection. Overall the practice is rated as good.

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

  • Risks to patients were assessed and well managed.
  • There was a clear leadership structure and staff felt supported by management who identified and mitigated risks. The practice proactively sought feedback from its staff which it acted on.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 26 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Eden Surgery on 26 January 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe and well led services. It was rated good for providing effective, caring and responsive services. All the population groups inspected were rated requires improvement overall.

Our key findings were as follows:

  • Systems were generally in place to keep patients safe and to protect them from harm. However, robust procedures were not followed in respect of staff recruitment, the management of controlled medicines and infection control.
  • Improvements were required to the operation of systems designed to regularly assess and monitor the quality of service provision.
  • Most staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • There was a clear leadership structure and staff felt supported by management. However, the practice had not proactively sought feedback from staff and as a result some were not fully aware of the practice vision and values.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Most patients said they found it easy to make an appointment and there was continuity of care, with urgent appointments available the same day.
  • Performance management data showed patient outcomes were good and mostly above average for the locality.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from the Patient Participation Group (PPG).
  • Information about services and how to complain was available and easy to understand.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.

The areas where the provider must make improvements are:

  • Ensure robust systems are in place for assessing and monitoring the quality of services provided. This includes arrangements for infection control, medicines management, staff training and development.

  • Ensure documentary evidence of appropriate recruitment checks on staff is maintained.

In addition the provider should:

  • Ensure audits complete their full audit cycle in order to demonstrate improvements made to practice.
  • Ensure that staff are aware and identify with the practice vision and values.
  • Ensure a register for all equipment used in the practice is kept for auditing purposes.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice