This practice is rated as Good overall (Previous inspection 21 April 2016 - Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Falkland House Surgery on 24 April 2018 as part of our inspection programme.

At this inspection we found:

• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice took action and improved their processes.
• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a focus on continuous learning and improvement at all levels of the organisation.
• There was a clear leadership structure and staff told us they felt respected, supported and valued. They felt part of a team and were proud to work in the practice.

The areas where the provider should make improvements are:

• Review the documenting processes for completing actions identified within risk assessments.

• Develop a programme of clinical audit to identify new topics and ensure second cycles of existing audits are completed.

• Encourage learning from feedback and events is shared with all staff.

• Monitor systems and processes to support good governance more closely to ensure they are completed in a  timely manner.

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 Dr S C Eilbeck and Dr T R Cossham on 21 April 2016. Overall the practice is rated as good.

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

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills and expertise to deliver effective care and treatment to patients and this was maintained through a programme of continuous development to ensure skills remained current.
• Patients told us staff were exceptionally caring, they were treated with compassion, dignity, respect and they were involved in their care and decisions about their treatment. Feedback from patients about their care and treatment was consistently strong and positive. National GP patient survey data published 7 January 2016 showed patient satisfaction was very high with 100% of patients saying they had confidence and trust in the last GP they saw or spoke to (national average 95%).
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Information about services and how to complain was available and easy to understand.
• Patients 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 registered provider was aware of and complied with the requirements of the Duty of Candour.
• The practice had in the previous month seen its list size increase by approximately 700 patients due to the closure of a nearby practice. They had been very proactive in getting to know the background of these new patients and had recruited an extra doctor to meet the additional demand on the practice.

The area where the provider should make improvement is:

• The practice should consider the need to have a defibrillator on site to deal with medical emergencies and complete a formal risk assessment.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice