Firs Surgery

We carried out an announced comprehensive inspection) at Firs Surgery on 28 November 2023. Overall, the practice is rated as good.

The ratings for each key question are as follows:

Safe - requires improvement

Effective - requires improvement

Caring - good

Responsive - good

Well-led - requires improvement

Following our previous inspection on 1 September 2017, the practice was rated good overall and for all key questions.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. The focus of the inspection included a review of all key questions.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing and in person.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A site visit.
• Conversations with members of the practice’s patient participation group.

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

We found that:

• The practice had some systems to keep patients safe and protected them from avoidable harm. This included areas such as safeguarding, recruitment, infection prevention and control and the management of the premises. However, there were some inconsistencies in the management of medicines which needed review.
• There were systems for managing incidents and complaints.
• Patients mostly received effective care and treatment that met their needs. Our review of clinical records found appropriate follow up of patients with or at risk of long-term conditions with the exception of diabetes where some improvements were needed.
• Uptake of childhood immunisations and cancer screening programmes were below national targets and national averages which the practice advised were due to the challenges within their population demographics.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care. Patient feedback was very positive about how they were treated.
• The practice was proactive in working with external agencies to provide patients with access to a range of social and wellbeing support and to improve inclusivity within the service.
• Patients could access care and treatment in a timely way. Results from the latest GP national patient survey showed questions relating to access scored above local and national averages.
• At the time of inspection, the practice was going through changes in leadership. There was a passion among the practice team to provide high-quality, person-centred care. However, discussions around governance and learning were not always documented or clearly showed the ongoing monitoring and oversight of the service.

We found two breaches of regulations. The provider must:

• 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.

The areas where the provider should make improvements are:

• Improve the recording of staff immunisations in line with national guidance and undertake risk assessment as appropriate.
• Strengthen systems for managing safety alerts.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care