Glemsford Surgery

We carried out an announced inspection at Glemsford Surgery on Wednesday 20 July 2022. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe – Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

When this provider, West Suffolk Foundation Trust (WSFT) registered Glemsford Surgery location with CQC, they inherited the regulatory history and ratings of the predecessor. This is the first inspection of Glemsford Surgery under the registered provider WSFT who became the provider from May 2020.

Following our previous inspection of the predecessor location on 01 November 2016, 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 Glemsford Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive first inspection to rate a new location.

This included:

• Inspection of the key questions:
  • Safe
  • Effective
  • Caring
  • Responsive
  • Well-led

How we carried out the inspection

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

We have rated this practice as Good overall

We found that:

• We found patients with safeguarding identified had been discussed in safeguarding meetings however, we found no alerts on some patient’s records.
• The practice lacked a process to review historical MHRA alerts effectively. We found some medicine reviews hadn’t identified the safety alerts for the medicines prescribed.
• The practice had effective systems to ensure all emergency medicines and equipment were safe to use.
• We found some patients taking high risk medicines lacked consistent monitoring.
• We found some patients that had potential missed diagnosis of diabetes and chronic kidney disease. We also found some blood test results used when reviewing and monitoring some patients with long term conditions were out of date.
• Staff competency monitoring was carried out on a daily basis; however, this was not formally documented, and lacked the clinical oversight to ensure high risk drug monitoring was effective.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice respected patients’ privacy and dignity and patient confidentiality was maintained throughout the practice
• The practice 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, however some systems and processes introduced during or following our inspection needed to be embedded.

We found a breach of regulations. The provider must:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

• Continue to embed the process to monitor the appropriate level of antibiotic prescribing for uncomplicated urinary tract infections.
• Continue to review and improve the opportunities for patients to access health screening checks.
• Continue to engage in patient feedback/survey exercises to gain and act upon patient opinion to improve patient satisfaction.

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