We carried out an announced comprehensive inspection at Cotmore Surgery on 4 March 2019 as part of our inspection programme.

At the last inspection in October 2015 we rated the practice as good for providing safe, effective, caring, responsive and well-led services.

At this inspection, we found that the providers had satisfactorily moved in line with changes within the healthcare economy and had shaped the practice to sustain delivery of high-quality services.

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 and good for all population groups.

We rated the practice as good for providing safe, effective, caring, responsive and well-led services because:

• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care. The practice scored above local and national averages in the 2018 national GP patient survey for questions relating to the care and treatment provided.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed mostly promoted the delivery of high-quality, person-centre care.

We rated the practice as requires improvement for providing safe services because:

• Staff we spoke with demonstrated how to recognise and respond to safety concerns; however, records we viewed showed not all clinical staff had completed the required training. Following our inspection, the practice provided evidence of an action plan which showed staff were required to complete fire safety training by July 2019.
• The practice did not have a schedule in place for reviewing risk assessments for the management of Disclosure and Barring Service (DBS) checks and chaperoning.
• Risk assessments did not adequately mitigate risks associated with not stocking some suggested emergency medicines. Following our inspection, the practice reviewed arrangements and updated their risk assessment.

The provider should:

• Review systems and processes to ensure effective oversight of training needs and ensure that training provided satisfies published guidance and competency framework.
• Consider the need for a formal, regular review of risk assessments relating to Disclosure and Barring Service checks and associated risk assessments to ensure risks are considered and mitigated.
• Continue carrying out actions to improve the uptake of national screening programmes such as cervical screening.
• Continue reviewing arrangements and updating risk assessments to determine the range of emergency medicines held at the practice.
• Ensure a formal approach to managing significant events is established and embedded.

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

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cotmore Surgery on 2 October 2015. Overall the practice is rated as good.

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

• Staff we spoke with understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We saw evidence to demonstrate that learning was shared amongst staff.

• Risks to patients were assessed and well managed, with the exception of those relating to the control of substances hazardous to health.
• 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 we spoke with told us they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Information about services and how to complain was available and easy to understand with a complaints poster displayed in the waiting area and complaints information also found in the practice leaflet.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.

• A ramped access was available although assessments about whether other adjustments were required had not been made for example the need for automatic entrance doors, wider entrance doors or disabled toilets.
• The practice had a number of policies and procedures to govern activity, but some were overdue a review such as the Health and Safety policy.
• There was a clear leadership structure and staff we spoke with were motivated and felt supported by management. The practice had sought feedback from patients and had an active patient participation group in place.

We saw one area of outstanding practice:

• The practice had set-up a dedicated 24 hour telephone access to the GP for patients undergoing insulin initiation

The areas where the provider should make improvements are:

• Develop an action plan to address issues identified following infection prevention and control audit.
• Ensure a Health and Safety policy is available for staff to refer to.
• Consider the risks relating to control of substances hazardous to health.

Fire drills should be carried out at regularly.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice