Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the Old Station Surgery on 6 October 2015. A breach of legal requirements was found in that robust systems were not in place, to assess and mitigate health and safety risks across all three sites where services were provided. Overall the practice was rated as good with requires improvement for the safe domain.

After the comprehensive inspection, the practice wrote to us to say what action they had, and were taking to meet legal requirements in relation to the breach.

We undertook this desk based review on 15 July 2016 to check that the provider had completed the required actions, and now met the legal requirements. We did not visit the practice as part of this inspection. This report only covers our findings in relation to those requirements.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Old Station Surgery on our website at www.cqc.org.uk.

Our finding across the area we inspected was as follows:

The practice had taken appropriate action to meet the legal requirements in relation to the breach.

Overall the practice is rated good including the safe domain.

The systems to assess and mitigate health and safety risks across all three sites 

had been strengthened, to ensure the services were safe. 

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 Old Station Surgery on 6 October 2015. GP services are provided from the main surgery and two branch surgeries at Kirk Hallam and Cotmanhay. Overall the practice is rated as good.

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

• The practice had arrangements in place to deal with information about safety. Staff were aware of their responsibilities to report incidents and concerns and knew how to do this. Information about safety was documented and monitored. The practice had systems in place to share learning from significant events and incidents.
• Risks to patients and staff were generally well managed through ongoing checks but comprehensive risk assessments had not been completed in all areas.
• Data showed patient outcomes were in line with other practices in the locality. The practice had an ongoing programme of clinical audit which was used to drive improvement in performance and improve patient outcomes.
• Feedback from patients was positive about the practice. Patients told us they were treated with dignity and respect and supported to make decisions about their care and treatment.
• Information about how to complain was accessible and easy to understand. Information on changes made as a result of patient feedback to the patient participation group (PPG) was shared with patients on a noticeboard in the waiting area.
• Urgent appointments were usually available on the day they were requested and patients could access appointments at the main surgery or either of the two branch surgeries.
• The practice had a range of policies and procedures to govern activity and held regular meetings

The areas where the provider must make improvements are:

• Ensure all risks to patients and staff are robustly assessed and monitored including legionella.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice