Sandford Surgery

We carried out an announced comprehensive inspection at Sandford Surgery on 20 February 2019, as part of our inspection programme.

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 and good for all population groups.

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

• There were no overarching health and safety risk assessments or systems to mitigate risk as far as practically possible within the practice. In particular, fire safety and safety of gas and electrical installations.
• The practice was unable to fully demonstrate that staff had received training on safeguarding patients and infection control.
• There were shortfalls in the monitoring and storage of prescription stationery.
• Patient groups directives and patient specific directives used for administering medicines were not appropriately signed and authorised.
• There were shortfalls in Legionella management. We found that water temperatures checks had been carried out. However, the practice could not fully demonstrate that all risks had been minimised as far as possible. Records related to water temperature checks were incomplete.
• The practice could not demonstrate fully how significant events and alerts were acted upon and how learning was effectively shared with relevant members of staff to drive improvement and support continuous learning.

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

• The practice had a vision to support patients to lead healthy lives and to support and develop staff. The strategy had not been translated into meaningful and measurable plans at all levels of the service.
• There were shortfalls in systems and processes in place for good governance and the practice was unable to demonstrate fully how they monitored the overall running of the practice,
• There was limited evidence to demonstrate how systems and processes in place for using information from Quality and Outcomes framework results and exception reporting were used to improve performance.
• Risk assessment related to health and safety in the practice were not fully effective and did not demonstrate that risk was mitigated when possible.
• Documentation to demonstrate how the practice operated and associated policies and procedures were not effectively reviewed, relevant and easily accessible.
• Information sharing on significant events and alerts and learning from these was not fully shared with all relevant members of staff.
• The practice was unable to demonstrate what actions would be taken if there was an interruption to service provision. Business continuity plans relied on the use of a social media group app: WhatsApp, to communicate with staff members, not clear how cover was provided from other practices in the area if the premises could not be used.
• The practice could not demonstrate when training had been provided and how development needs identified during appraisals were addressed.

We rated the practice as good for providing effective, caring and responsive services. All population groups were rated as good:

• Patients received effective care and treatment that met their needs.
• 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.

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.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups, it will be re-inspected no longer than six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care