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Review carried out on 21 June 2019

During an annual regulatory review

We reviewed the information available to us about Captain French Surgery on 21 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 21 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Captain French Surgery on 21 April 2016. Overall, the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Lessons were learned when incidents and near misses occurred.
  • Most risks to patients were assessed and well managed.
  • 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. Data from the National GP Patient Survey published in January 2016 showed that patients rated the practice highly for the care they received. For example, 100% patients said they had confidence and trust in the last GP they saw or spoke to compared to the CCG average of 97% and the national average of 95%.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they were able to get an appointment with a GP when they needed one.
  • Urgent appointments were available on the day they were requested.
  • Extended hours appointments were available with a GP, nurse or healthcare assistant three mornings and one evening a week.
  • 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 practice was responsive to the needs of the population and worked with the local clinical commission group and other local practices to ensure services were provided that met the needs to the population.
  • Staff offered care that supported patient centred end of life care; the practice was ranked second in the locality for this provision.

The areas where the provider should make improvement are:

  • Review the arrangement for training at the practice to include regular fire training for staff.
  • Review the arrangements for clinical audit; demonstrate a clear link between audits and quality improvement.
  • Complete a risk assessment of the window blinds used at the practice to reduce potential hazards for children and vulnerable adults.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 29 April 2014

During a routine inspection

Captain French Surgery recently started to provide the service from the Gillinggate Centre. The practice operated a weekday service for over 9000 patients in the Kendal area. It provided extended services so opened at 7.30am three days a week and closed at 6.30pm. At least once a week the centre closed around 7pm. Captain French Surgery was responsible for providing primary care, which included access to GPs, minor surgery, family planning as well as ante and post natal care. Cumbria Health on Call (CHOC) provided an out of hours service for patients who used the Captain French Surgery.

The patients we spoke with and who completed our comment cards were very complimentary about the care provided by the clinical staff; the overall friendliness and behaviour of all staff. Patients reported that they felt that all the staff treated them with dignity and respect.

We found that the practice had listened to patient comments and took action to improve their service.

A range of appointments were available including telephone consultations and people could book these both in person, over the phone or on-line.

The building was well-maintained and very clean. Effective systems were in place for the oversight of medication. Clinical decisions followed best practice guidelines.

We found that the leadership team was very visible. There were excellent governance and risk management measures in place.

We found that the practice had met the regulations and provided services that were safe and effective.