Archived: Old School Surgery

We carried out an announced comprehensive inspection at Old School Surgery on 17 October 2019 as part of our inspection programme. This was the providers first inspection since registering with CQC in October 2018.

We based our judgement of the quality of care at this service 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.

We have rated this practice as Requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

• There were identified issues with infection control audits and significant event reporting systems and processes, which were not always appropriately monitored to ensure they were always effective.

We rated the practice as requires improvement for providing effective services because:

• The quality improvement programme was not always effective.
• The practice could not demonstrate that the immediate and ongoing needs of patients with long-term conditions and mental health conditions were being fully assessed.
• There was no evidence of an induction program.
• Staff appraisals had not all been completed.

We also rated the practice as good for providing caring, responsive and well -led services because:

There were comprehensive systems to keep people safe, which took account of current best practice.

Patients received effective care and treatment that met their needs.

The way the practice was led and managed promoted the delivery of good quality, person-centre care.

Staff dealt with patients with kindness and respect. They involved them in decisions about their care.

The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Systems and processes to ensure good governance were good overall but some areas required time to be embedded to ensure they were implemented effectively.

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

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider the provider should make improvements:

• Continue with their plan to ensure annual infection control and prevention audits are completed.
• Continue to monitor and assess the effectiveness of the practice action plan, for driving quality improvement.
• Continue to improve the identification of carers, to ensure they receive appropriate care and support.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Bennyworth BS BMedSci MRCGP
Chief Inspector of General Practice