The areas where the provider must make improvements as they are in breach of regulations are:

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

The area where the provider should make improvements is:

• Review and improve the processes for collating and analysing verbal complaints.
• Continue to monitor and improve patient experience in relation to access to appointments.

Details of our findings and the evidence table supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall, but as Requires Improvement for providing responsive services. A previous inspection, carried out on 23 February 2016 rated the practice as requires improvement overall, with the safe and effective key questions rated as requires improvement. Breaches of regulation were identified on that occasion. A focused follow up inspection carried out on 10 August 2016 found the practice had carried out the necessary improvements; and was rated as good overall, with the safe and effective key questions rated as good.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Eightlands Surgery on 11 January 2018. The inspection was carried out as part of our inspection programme

• The practice had clear systems to manage risk so that safety incidents were appropriately managed. We saw evidence that when incidents occurred, the practice had an open and transparent system for reporting in place. They demonstrated that processes were improved as a result of incidents; and learning was shared to prevent future recurrences.
• Staff recruitment and induction processes were appropriate. The practice was in the process of recruiting additional clinical staff into the practice.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Patients told us they found the telephone appointment system difficult to use. The practice showed us evidence of efforts they were continuing to make to improve the efficiency and responsiveness of the telephone system.
• There was a focus on continuous learning and improvement at all levels of the organisation. We saw evidence that staff had been encouraged to develop within their roles, and progress onto other roles within the practice when appropriate.

The areas where the provider should make improvements are:

• Review and improve the frequency of infection prevention and control audits carried out in line with the latest guidance and complete any identified actions required.
• Review and improve the supervision and review process for newly appointed clinical staff when appropriate.
• Continue to review, act on and improve patient satisfaction in accessing services at the practice. Patient satisfaction in these areas was significantly below local and national averages.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Eightlands Surgery on 23 February 2016. The practice was rated as requires improvement for safe and effective. The overall rating was requires improvement. Breaches of legal requirements were found.

Following on from the inspection the practice provided us with an action plan detailing the evidence of the actions they had taken to meet the legal requirements in relation to providing safe and effective services to the patients.

We undertook a desk based review on 5 August 2016 and visited the practice on 10 August 2016. This was to review in detail the information the practice had sent to us and to confirm that the practice were now meeting legal requirements. This report only covers our findings in relation to those legal requirements.

The full comprehensive report which followed the inspection in February 2016 can be found by selecting the 'all reports' link for Eightlands Surgery on our website at www.cqc.org.uk.

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

• Patient Group Directions and Patient Specific Directions had been adopted by the practice to allow nurses to administer medicines in line with legislation.

• The practice could demonstrate how they ensured role-specific training and updating for relevant staff. For example, for those reviewing patients with long-term conditions.

• Systems were in place to effectively manage the safe storage of vaccines.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Eightlands Surgery on 23 February 2016. Overall the practice is rated as requires improvement.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. However, we found that not all lessons from such incidents were implemented fully.
• Staff training needs were not adequately addressed 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.
• Information about services and how to complain was available and easy to understand.
• National and practice survey data showed that patients were able to get appointments when they needed them.
• Data showed patient outcomes were similar to the locality and nationally.
• Extended hours appointments were available for working people and urgent appointments were 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. The practice proactively sought feedback from staff and patients, which it acted on.
• The practice had an active patient participation group who met with practice staff regularly.
• The provider was aware of and complied with the requirements of the Duty of Candour.
• The GP’s capacity was limited and the practice relied on locum clinicians.

The areas where the provider must make improvements are:

• The practice must ensure that nurses comply with regulations with respect to the administration of medicines in accordance with Patient Group Direction (PGD) guidance.
• Provide staff with appropriate role specific training and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice. The practice must ensure staff receive training to ensure effective cold chain management in the practice.

In addition the provider should:

• Ensure there are systems and processes in place for clinical staff regarding Patient Safety Alerts, that are issued from the Medicines and Healthcare products Regulatory Agency (MHRA).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice