Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Surgery on 12 October 2017. Overall the practice is rated as good.

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

• Safety concerns were not consistently recorded and shared. The practice’s processes and procedures for managing significant events were not consistently followed across the practice. Where patients had been affected, it was unclear from the records whether or not the patient had been informed of the incident as soon as reasonably practicable, received reasonable support, truthful information, a written apology and was told about any actions to improve processes to prevent the same thing happening again.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• 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. However, management oversight of staff training and recording of staff induction required review.
• 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 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 the requirements of the duty of candour. No notifiable safety incidents had occurred.

The areas where the provider must make improvement are:

• Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvement are:

• Formalise the staff induction programme and continue to monitor staff training to ensure clear and organised records of all training undertaken are maintained.

• Formalise a programme of quality improvement including clinical and internal audit.

• Review the time of the practice meeting to ensure all staff are able to attend.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Surgery on the 12 October 2017. At this inspection we rated the practice as good overall and for the key questions of effective, caring, responsive and well-led with the exception of safe which we rated requires improvement. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for The Surgery on our website at www.cqc.org.uk.

We carried out an announced focused inspection at The Surgery on 29 May 2018. This inspection was carried out to review the actions taken by the practice to improve the quality of care and to confirm whether the practice was providing a safe service and was now meeting legal requirements.

The overall rating for the service is Good.

The key questions are rated as:

Are services safe? - Good

At this inspection, we found:

• The practice had reviewed their systems and procedures for significant events and this ensured the consistent recording of significant events.
• Patients would be informed and offered an apology if involved in a significant event.
• New staff had a written induction program to follow.
• The practice had installed a new e learning program to ensure that staff completed their essential training. This provided the practice manager with an overview of staff training.
• The practice had carried out clinical internal audit.
• The practice held the monthly practice meetings on different days of the week to ensure that all staff could attend.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice.