Ormesby Village Surgery, Ormesby St. Margaret, Great Yarmouth.
Ormesby Village Surgery in Ormesby St. Margaret, Great Yarmouth is a Doctors/GP specialising in the provision of services relating to diagnostic and screening procedures, family planning services, maternity and midwifery services, services for everyone, surgical procedures and treatment of disease, disorder or injury. The last inspection date here was 6th April 2018
Ormesby Village Surgery is managed by Coastal Villages Practice (Ormesby Village Surgery) who are also responsible for 2 other locations
Contact Details:
Address:
Ormesby Village Surgery Pippin Close Ormesby St. Margaret Great Yarmouth NR29 3RW United Kingdom
We carried out an announced comprehensive inspection at the Ormesby Village Surgery on 18 September 2017. The practice was rated as good for providing effective, caring, responsive and well led services and requires improvement for providing safe services. Overall the practice was rated as good. The full comprehensive report following the inspection on 18 September 2017 can be found by selecting the ‘all reports’ link for Ormesby Village Surgery on our website at www.cqc.org.uk.
We undertook a follow up focused inspection of Ormesby Village Surgery on 14 March 2018. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements and also additional improvements made since our last inspection.
Overall the practice is still rated as good, and now good for providing safe services.
Our key findings were as follows:
The practice no longer used fabric curtains. All curtains were disposable and there was a clear policy outlining how often these needed to be changed and how to dispose of them correctly.
The practice had access to the hepatitis B immunity of the cleaning staff employed by an external company.
All staff that worked in the dispensary had undertaken a competency assessment.
The practice had reviewed the standard operating procedures for the dispensary for both sites. These were practice specific and had been reviewed and signed by all staff.
The security of the dispensary at the practice’s branch location in Caister had been reviewed and improved.
The practice had implemented a new policy for the checking of equipment and medicines in clinical rooms. Medicines and equipment we checked in clinical rooms were in date.
The practice kept logs of expiry date checks in the dispensary.
There was evidence that near misses were appropriately recorded for both dispensaries.
The practice had reviewed the GP patient survey results relating to access and had highlighted the areas of lower than average performance. They had implemented an action plan which included:
Liaising with the clinical commissioning group to be part of a pilot to provide extended hours as part of a hub with three other local practices, due to launch in July 2018, to offer weekend and evening appointments. The practice would provide GPs and nurses in conjunction with the other practices.
Providing additional nursing appointments.
All receptionists planned to complete a care navigator course to improve patient access to local support groups.
Adapt the appointments system to be more flexible to meet demand. For example, the practice had put on extra clinics for chest complaints and minor illnesses during the winter period.
Liaison with the patient participation group (PPG). They had devised a patient survey to gain feedback about the changes they had implemented. The PPG were reviewing the survey questions and amending them prior to conducting the survey in April 2018.
The area where the provider should make improvements:
Update the policy relating to the process for monitoring expiry dates on equipment.
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Ormesby Village Surgery on 18 September 2017. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
There was a clear leadership structure and staff felt supported by management. The practice ensured that communication across all four sites was clear and defined.
There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
The practice had several comprehensive risk assessments completed.
The practice had two dispensaries and we found that improvements were needed in relation to the dispensary at the Caister site. This included recording of near misses, staff training, and security. We found the standard operating procedures were not practice specific at this site and there was no system or process to record that stock was regularly checked to ensure it was safe to use.
We found all the premises to be clean. We found fabric curtains at two sites however there was no protocol for the frequency or method of cleaning these.
We found out of date items including scissors, dressings and stitch cutters. These were removed immediately.
Staff had received training on safeguarding children and vulnerable adults relevant to their role. Staff had received additional training relating to female genital mutilation and ‘prevent’ (a government approved anti-terrorism training course).
Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
The practice was above local and national averages for cervical screening.
Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
The practice hosted the ‘memory joggers’ group for patients living with dementia.
There was a clear leadership structure and staff felt supported by management. The practice ensured that communication across all four sites was clear and defined.
The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
The areas where the provider must make improvements are:
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:
Continue to assess and ensure improvement to national GP patient survey results relating to patient satisfaction for access.
Letter from the Chief Inspector of General Practice
On 21 October 2014 we carried out an announced inspection of Coastal Villages Practice (Ormesby Village Surgery), Ormesby, Great Yarmouth, Norfolk, under our new approach of inspection of primary medical services. The practice had three branch surgeries, two of which were included in our inspection.
We found that the practice was good overall across all the areas we inspected.
Our key findings were as follows:
The practice was safe, well led, effective, caring and responsive.
Staff recognised and understood the needs of patients and tailored access to care and treatments to meet these needs.
The practice was working in partnership with other health and social care services to deliver individualised care.
The practice provided a safe service in an environment which was well managed and risks to staff and patients were identified and minimised.
Staff were trained and supported to deliver high quality patient care and treatment and to improve outcomes and experiences for patients
However, there were areas of practice where the provider needs to make improvements.
Importantly, the provider should:
Ensure there is an effective review of complaints handling and procedures in place to ensure that where appropriate a significant event review is put in place alongside the complaints procedure.
Ensure there are suitable security arrangements in place for the safe storage of medicines in clinical areas and all associated prescribing forms and paperwork across the practices.
Ensure that all staff who may be used for chaperoning services were informed about their role and the implications for protecting both the patient and the GP as a chaperone.
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