Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sea Mills Surgery on 21 July 2015. Following our comprehensive inspection overall the practice was rated as good with requires improvement for the safe domain. Following that inspection we issued two requirement notices. These notices were due to a breach of Regulation 15 of The Health and Social Care Act (Regulated Activity) Regulations 2014, Premises and Equipment and Regulation 17 Good Governance. The requirement notices were for the practice to implement the necessary changes to ensure patients who used the service were protected against the risks associated with infection prevention and to monitor the quality and safety of the service. A copy of the report detailing our findings can be found at www.cqc.org.uk.

We undertook this focused inspection on 29 June 2016 to follow up the requirement to assess if the practice had implemented the changes necessary to ensure patients who used the service were protected against the risks associated with infection prevention and to monitor the quality and safety of the service.

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

• The practice had in place a regular programme and documented audits for infection control.

• The practice had reviewed and refined their processes for reporting incidents and significant events.

• We found the practice had reviewed their arrangements for the implementation of health and safety and had introduced new policies and procedures and ensured the staff had completed appropriate training.

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 Sea Mills Surgery on 21 July 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well led, effective, caring and responsive services. However we found the practice required improvement for providing safe services. It was also rated as good for providing services for all of the population groups.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• 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.
• 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.
• There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.

• The practice facilities were designed and equipped to meet patients’ treatment needs.
• Information about how to complain was available and easy to understand.
• Appointments were not limited by 10 minute slots and were able to use their clinical judgements to book appropriate length of appointments for patients.
• The systems and processes intended to keep the service safe were not always fully implemented, for example, the practice had information about infection control audits not completed an infection control audit and we found a number of areas where the risk of infection had not been assessed and remedial action put into place.

There were areas of practice where the provider needs to make improvements.

Importantly the provider must:

• Comply with the guidance from the Department of Health, Code of Practice on the prevention and control of infections and related guidance.
• Systems to assess, monitor and improve the quality and safety of the service must be improved particularly in areas such as fire safety and regular maintenance.

In addition the provider should:

• Ensure that staff training is recorded centrally so that the practice can easily demonstrate staff had the skills to meet patient needs.
• Ensure that, where applicable, the professional registration of staff is checked and a record kept of the current registration.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as Good overall. (Previous rating July 2016 – Good)

The key questions at this inspection 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 Sea Mills Surgery on 11 October 2018 as part of our inspection programme.

At this inspection we found:

• There was a clear commitment form the team that patients were the priority of the practice this was evidenced by feedback from patients and from staff team members.
• The was a strong team ethos and culture of working together for a common aim.
• There were areas within the practice which had improved since our previous visit and they had adapted and embraced the opportunities for change.
• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• 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.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were always able to access care when they needed it.
• There was a focus on continuous learning and improvement at all levels of the organisation; we found learning was implemented at the practice to improve services for patients.

The areas where the provider should make improvement is:

• Review how they record the outcome for safety alerts.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.