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The Royal Crescent Surgery Good

Inspection Summary

Overall summary & rating


Updated 25 October 2018

This practice is 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 Royal Crescent Surgery on 8 November 2017. Overall 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 and for people with long-term conditions population group. The full comprehensive report of the 8 November 2017 inspection can be found by selecting the ‘all reports’ link for Royal Crescent Surgery on our website at .

This inspection was an announced focused inspection carried out on 25 September 2018. The purpose 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 8 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 and for people with long term conditions. Overall the practice remains rated as good.

At this inspection we found:

  • The practice had reviewed and improved systems and processes to ensure the temperature of vaccine fridges were monitored and actions were taken when there were signs that the fridges had operated outside of the normal range.
  • 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.
  • Systems and processes had been reviewed to ensure all patients with long term conditions were reviewed including those who had previously been excepted from reviews.
  • The practice had increased the number of patients identified as carers.

The areas where the provider should make improvements are:

  • Continue to monitor and improve uptake for reviews of patients with long term-conditions.
  • Provide written guidance setting out the standards for the management of test results in the practice.

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 25 October 2018

We rated the practice as requires improvement for providing a safe service at the last inspection on 8 November 2017. We found gaps in systems for the safe management and storing of medicines.

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 25 September 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.
  • 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 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.

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.
  • There was a process in place for the appropriate management of test results. However, this was not recorded. Test results would be sent to the GP who initiated the test. If the GP was away, the remaining GPs would pick up any outstanding results and deal with it in an appropriate and timely way.

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. At the last inspection in November 2017, we found the practice had not taken action when there were signs that one of the vaccine fridges had operated outside of the normal range. At this inspection, we found that the practice had improved the recording of the temperature of vaccine fridges. In addition to monitoring the fridge temperatures daily, they had purchased a device to monitor the fridge temperatures over a 24-hour period. The data from this device was downloaded weekly to check that fridges were operating effectively.
  • 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.
  • 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.

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.
  • The practice had overhauled their meeting structure to make them more effective and focused on monitoring and discussing patient safety.

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 undertaken a further review of and improved their system for recording safety alerts since the last inspection.

Please refer to the evidence tables for further information.



Updated 25 October 2018

At the last inspection in November 2017, we rated the practice as good for providing effective services overall. All population groups were rated good, except for patients with long term conditions where we rated the practice as required improvement. This was because there were a high number of patients with long-term conditions who had been identified as not being appropriate for condition reviews. We found there was limited rationale why those patients were not appropriate to be reviewed.

We also told the practice at the last inspection in November 2017 that they should continue to improve the identification of carers so these patients receive appropriate support. The practice told us they had identified and implemented new ways to identify carers. For example, clinicians were reminded to ask patients if they had carers responsibility when appropriate. New patients were also asked if they were a carer at registration. The practice had identified 82 patients as carers which was approximately 1% of the practice population. This was an improvement from the last inspection where they had identified 73 patients and their practice population had increased since the last inspection.

At this focused inspection on the 25 September 2018, we rated the practice as good for providing effective services for patients with long term conditions.

  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training. An additional nurse had been recruited recently and they were also undertaking specialist training in the management of diabetes.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma. The nurse who specialised in respiratory condition also told us they received reports from the hospital if patients had been admitted following an exacerbation of their condition. The nurse would then contact the patient to check if they needed additional support and invited them for an appointment if necessary.
  • Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention. People with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension)
  • The practice’s performance on quality indicators for long term conditions was improving compared to previous years. We discussed the practice’s performance in relation to quality indicators and they explained that there had been staffing issues which impacted on reviews of long term conditions. There was now a lead GP who had oversight of diabetes reviews. Since the last inspection, the practice had recruited another nurse who was undertaking training in diabetes. The practice held regular clinical meetings monthly where performance on quality indicators was reviewed and clinical staff was updated on current performance and any further actions required. Staff we spoke with demonstrated a better understanding of the ways the practice were driving improvements for reviewing patients with long term conditions. Patient records we reviewed showed patients were invited for reviews and where they had been excepted, there was rationale for the decision.

Please refer to the evidence tables for further information.






Checks on specific services

People with long term conditions


Families, children and young people


Updated 8 December 2017

Older people


Updated 8 December 2017

Working age people (including those recently retired and students)


Updated 8 December 2017

People experiencing poor mental health (including people with dementia)


Updated 8 December 2017

People whose circumstances may make them vulnerable


Updated 8 December 2017