The Care Quality Commission
  • Doctor
  • GP practice

The Friendly Family Surgery

Overall: Good read more about inspection ratings

Welbeck Road, Bolsover, Chesterfield, Derbyshire, S44 6DE (01246) 826815

Provided and run by:
Dr Karabi Ray

Important: The provider of this service changed - see old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Friendly Family Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Friendly Family Surgery, you can give feedback on this service.

02 August 2021

During an inspection looking at part of the service

We carried out an announced, focused inspection at The Friendly Family Surgery on 2 August 2021. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions: safe, effective and well-led. Due to assurances we received from our review of information, we carried forward the ratings of good from our previous inspection in January 2020 for the following key questions: caring and responsive. The practice is rated as Good overall and in all key questions.

Following our previous inspection on 27 January 2020, the practice was rated Requires Improvement overall. It was rated requires improvement in the key questions safe, effective and well-led and good in caring and responsive.

The full report for the previous inspection can be found by selecting the ‘all reports’ link for The Friendly Family Surgery on our website at www.cqc.org.uk

Why we carried out this inspection.

This inspection was a focused inspection to follow up on:

  • Breaches in regulations relating to safe care and treatment and good governance.
  • Two best practice recommendations:
  • Continue to implement the changes made to the in-house approach to the management of long-term conditions and improve patient outcomes in line with local and national averages.
  • Improve engagement with national cancer screening and childhood immunisation programmes.

How we carried out the inspection

Throughout the Covid-19 pandemic the Care Quality Commission (CQC) has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

Our findings

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
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall and good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • The practice maintained safeguarding lists of children at risk and vulnerable adults. They also maintained a ‘watch’ list for patients with the potential to develop safeguarding concerns who may require additional support.
  • There were protocols and searches in place for the monitoring of patients prescribed high risk medicines and diagnosis of long-term conditions. However, we identified a small number of patients who had not received the required monitoring or potentially had a misdiagnosis. The provider sent an action plan to the CQC immediately after our inspection demonstrating the actions they had taken to address these findings.
  • Systems for tracking prescription stationery throughout the practice were updated during our inspection.
  • There was a system in place for reporting and acting on significant events however, the reporting forms lacked detail.
  • Patients received effective care and treatment that met their needs.
  • The practice had achieved 100% for all five childhood immunisation uptake indicators and exceeded the WHO based national target of 95%.
  • The practice had adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. 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 and supported staff.
  • Staff told us that they could not have asked for more support than that provided by the provider throughout the Covid-19 pandemic and that there was an open and honest culture within the practice.

Whilst we found no breaches of regulations, the provider should:

  • Continue to act on their action plan for monitoring patients prescribed high risk medicines. Particularly medicines used for the treatment of heart failure, mood stabilisation and prevention of stroke. Continue to act on their plan to mitigate risks of misdiagnosis of long-term conditions such as diabetes or chronic kidney disease.
  • Continue to embed into practice the protocol changes made to track prescription stationery throughout the practice.
  • Update safeguarding policies to include all the categories of abuse. For example, human trafficking or modern slavery.
  • Enhance the level of detail in the significant event analysis forms to support staff to understand and learn from the events.

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

27 January 2020

During a routine inspection

We carried out an announced comprehensive inspection at The Friendly Family Surgery on 27 January 2020 as part of our inspection programme. The inspection was triggered by a change in registration status with the Care Quality Commission (CQC). The practice was previously registered as a partnership but became a single-handed GP provider which registered with the CQC in May 2019.

Previous inspections of this location under the previous service provider can be found on our website at .

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. The practice was rated as requires improvement in the safe, effective and well-led domains, and rated as good for providing caring and responsive services.

We rated the population groups of long-term conditions as requires improvement, whilst the other population groups were rated as good. This was due to lower outcomes achieved for the management of diabetes.

We rated the practice as good for providing caring and responsive services because:

  • Staff dealt with patients with kindness and respect and 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.

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

  • The arrangements to review child safeguarding concerns with the practice team, and the wider health and social care team, were not in place at the time of our inspection.
  • Professional registrations were not being reviewed on an annual basis.
  • The process for risk assessing the environment, incidents, and some internal procedures required strengthening to provide greater assurance that risk was being managed proactively.
  • Infection control management needed a stronger focus. This included supplementary training for infection control leads to support the process of infection control audits, and procedures such as the cleaning of medical equipment.
  • Oversight of some processes relating to medicines management required strengthening. This included adherence to Patient Specific Directions (PSDs), the oversight of non-medical prescribers, and the management of vaccines and emergency medicines.
  • The distribution of safety alerts, for example Medicines and Healthcare products Regulatory Agency (MHRA) alerts, were not inclusive of all prescribing clinicians. Whilst we saw evidence that these had been followed up, these were largely managed by the lead GP and we did not find assurances that the wider team participated in this process.
  • Some consumable items including specimen pots, wound irrigation solution and ECG pads which were found to have past their expiry dates.

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

  • Staff appraisals for nursing staff and the practice manager were out of date.
  • Assurances that update training for nursing staff including cervical sample taker training updates and immunisations training updates were not available at the time of the inspection.
  • Outcomes from the Quality Outcomes Framework for patients with diabetes were below local and national averages. This impacted on the long-term condition population group.

We rated the practice as requires improvement for providing well-led services because:

  • Our inspection identified that partners and managers needed a more proactive approach to address the requirement to produce clear evidence of their compliance with our regulations.
  • The responsibilities, roles and systems of accountability to support good governance and management were not always effective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way (Please see the specific details on action required at the end of this report).
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. (Please see the specific details on action required at the end of this report).

In addition, the practice should:

  • Continue to implement the changes made to the in house approach to the management of long-term conditions, and improve patient outcomes in line with local and national averages.
  • Improve engagement with national cancer screening and childhood immunisation programmes.

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.