Letter from the Chief Inspector of General Practice

This is the report from our inspection of Nutgrove Villa Surgery. Nutgrove Villa Surgery is registered with the Care Quality Commission to provide primary care services.

We undertook a planned, comprehensive inspection on the 4 February 2015 at Nutgrove Villa Surgery. We reviewed information we held about the services and spoke with patients, GPs, and staff.

The practice was rated as good overall.

Our key findings were as follows:

• There were systems in place to mitigate safety risks. The premises were clean and tidy. Systems were in place to ensure medication including vaccines were appropriately stored and in date.

• Patients had their needs assessed in line with current guidance and the practice promoted health education to empower patients to live healthier lives.

• Feedback from patients and observations throughout our inspection highlighted the staff were kind, caring and helpful.

• The practice was responsive and acted on patient complaints and feedback.

• The practice was well led. The staff worked well together as a team and had regular staff meetings and training.

However there were some areas for improvement.

The provider should:

• Resource additional training and ensure all members of staff receive training in adult safeguarding.
• Carry out risk assessments to ensure staff are suitable to act as chaperones.
• Ensure that the clinical governance policy is revised to reflect the current practice protocols and responsibilities and make all staff aware of this.
• Make better use of the website for patient information and capturing patients’ feedback especially with regards to the younger population.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Nutgrove Villa Surgery on 21 March 2019.

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 requires improvement overall.

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

• The practice did not have appropriate systems in place for the safe management of medicines.
• Adrenaline was not available in the rooms in which babies were immunised.
• Systems in place did not ensure that test and laboratory results were always dealt with appropriately.
• The practice did not always learn and make service-wide changes when things went wrong.

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

• There was limited monitoring of the outcomes of care and treatment.
• Limited clinical audits had been completed and the provider had not initiated a program of ongoing and comprehensive clinical audits which could trigger change and improvements.

We rated the practice as requires improvement for providing well-led services because:

• While the practice had a clear vision, that vision was not supported by a credible strategy.
• Systems were not in place to monitor the overall governance arrangements in place.
• The practice had clear processes for managing risks, issues and performance, however this was not monitored for effectiveness.
• Systems and processes for learning, continuous improvement and innovation were not always used appropriately.

These areas affected all population groups so we rated all population groups as requires improvement.

We rated the practice as good for providing caring and responsive services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements is:

• Audit whether consent to treatment is always legally obtained.
• Review system or policies to manage uncollected prescriptions

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