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Review carried out on 20 June 2019

During an annual regulatory review

We reviewed the information available to us about The Gardens Surgery on 20 June 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 5 August 2016

During a routine inspection

We carried out an announced comprehensive inspection of The Gardens Surgery on 25 November 2015 where the practice was rated good overall. However breaches of regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified, and we rated the practice to require improvement for providing safe services.

The specific concerns in the previous inspection related to safety were:

  • Not all staff had received the appropriate level of safeguarding or basic life support training.

  • Not all staff who acted as chaperones had received a Disclosure and Barring Service check prior to being designated a chaperone.

  • The practice was not conducting fire drills on a regular basis.

  • Prescriptions kept in printers were not always appropriately stored and secured when clinical rooms were vacant.

  • Children’s oxygen masks were not stored with the practice’s supply of oxygen which would have hindered their ability to respond effectively in an emergency.

  • Some staff were not aware of the practice’s business continuity arrangements and there was no member of staff who had overall responsibility for disaster recovery.

In addition to this we found that some staff members had not been appraised within the previous 12 months.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 17(1).

We undertook this focussed inspection on 5 August 2016 to check that they had followed the action plan provided and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Gardens Surgery on our website at

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services.

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

  • All staff had completed basic life support and safeguarding training within the last 12 months.

  • All staff had received the requisite level of chaperoning training and background checks.

  • The practice had carried out a fire drill where action points were learned from and implemented.

  • The practice had implemented systems and processes to ensure that prescriptions held in printers were stored securely.

  • The practice had stored the oxygen masks with the practice’s oxygen supply.

  • The practice had made improvements to its business continuity arrangements. There were now packs with emergency supplies which could be used if the premises were not in operation and there was a designated person who was responsible for overseeing and making any required changes to the practice’s business continuity arrangements.

In addition to addressing the breaches of regulation which impacted on safety, the practice had taken additional action on the basis of our last report:

  • The practice was in the process of giving reception staff customer service training and most staff appeared to have completed this.

  • All staff had been appraised.

Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice

Inspection carried out on 25 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Gardens Surgery on 25 November 2015. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • There were not adequate systems in place to assess, monitor and mitigate risks to people using the service.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • 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 that there was continuity of care, with urgent appointments available the same day either at the surgery or at the local extended primary care service.
  • 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 provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider should make improvement are:

  • Should ensure that procedures in place for monitoring the use of prescriptions are always adhered to.

  • Should ensure that all staff have received the appropriate level of safeguarding training.

  • Should continue with plan for customer service training to be provided to all reception staff.

  • Should ensure that all staff receive an annual appraisal.

  • Should put systems in place to ensure that all staff acting as chaperones duties have been DBS checked prior to being designated a chaperone.

  • Should ensure that all staff receive regular basic life support training in accordance with national guidance.

  • Should ensure that regular fire drills are conducted within the practice.

  • Should ensure that childrens oxygen masks are stored with the practice's oxygen supply.

  • Should ensure that there are robust business continuity arrangements in place.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice