We carried out an announced focused inspection at Severnbank Surgery on 24 January 2019, to follow up on a Warning Notice we issued following our previous inspection on 2 October 2018. We did not rate the practice as part of this inspection.

On 2 October 2018 we carried out an announced comprehensive inspection at Severnbank Surgery of our inspection programme. We revisited the practice again on the 9 October 2018 to gather some additional information. We found there were breaches in the regulations relating to safe care and treatment, receiving and acting on complaints and good governance. Following this inspection, we sent the practice a Warning Notice setting out why they were failing to meet the regulations relating to safe care and treatment and requiring them to become compliant with this regulation by 31 January 2019. The full report on the October 2018, inspection can be found by selecting the ‘all reports’ link for Severnbank Surgery on our website at

This report covers the announced follow up focused inspection we carried out at Severnbank Surgery on 24 January 2019, to review the actions taken by the practice to improve the quality of care and to confirm that the practice was meeting legal requirements in relation to safe care and treatment.

At this inspection we found the practice had made significant changes and improvements to their systems and processes, and actions had been implemented to address the failings we itemised in the Warning Notice. For example:

• The practice had reviewed systems and processes to ensure emergency medicines were in date and easily accessible in the case of an emergency.
• Risks assessments had been carried out for the storage of hazardous substances.
• Fire drills had been undertaken and actions and learning identified for safely managing the situation in the event of a fire.
• The practice had reviewed systems in place for the processing of safety alerts. There were records in place to ensure actions taken were monitored and completed.
• Employed staff who required medical indemnity insurance had these in place.
• Quarterly meetings had been set up to review significant events and complaints to look for trends and whether they were appropriately dealt with.

In a few areas we found the new systems and processes where not yet fully embedded. Specifically:

• Systems had been introduced to ensure all Controlled Drugs (CDs) held in stock were accounted for from delivery to being issued to patients. However, the recording of these in the CD register were not always accurate.
• The practice had a process to review medicines dispensed in compliance aid boxes, however, we saw one medicine that had been packed in its original wrapping foil.
• There was no evidence that Patient Specific Directions (PSDs) were authorised in line with guidelines. (PSDs are written instructions, from a qualified and registered prescriber for a medicine including the dose, route and frequency or appliance to be supplied or administered to a named patient after the prescriber has assessed the patient on an individual basis.)
• Dispensing errors that reached patients were recorded and investigated but the dispensary did not have a process to record near-miss errors to promote learning and minimise the chances of similar errors occurring again.
• Recruitment checks had been carried out appropriately for employed staff. However up to date information was not available for locum GPs. For example, an up to date disclosure and barring service check (DBS), that they were registered with the appropriate registration body, and they had the appropriate medical indemnity insurance.
• Systems were in place for the monitoring of blank prescriptions forms. However, we found there were discrepancies in the records for blank prescription forms. Handwritten prescriptions pads were not tracked.

The practice remains in continued breach of regulations due to further actions required to ensure improvements continue to be made and embedded. Therefore, areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in safe way.

The areas where the provider should make improvements are:

• Review systems so that near miss errors in the dispensary are recorded and learning implemented to minimise the chances of similar errors occurring again.
• Review systems in place for the monitoring of blank prescription forms and implement system for the monitoring of handwritten prescription pads.
• Take actions so that access to medicines that requires refrigeration is restricted to authorise staff only.

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 of Severnbank Surgery on 19 January 2016. We found that the practice had breached a regulation relating to the safe delivery of services.

The practice required improvement for the provision of safe services to ensure that the risks associated with checking, maintaining and safely storing emergency equipment and medicines had been appropriately assessed. Overall the practice was rated as good.

Following the inspection the provider sent us an action plan detailing how they would improve the emergency equipment and medicine management systems ensuring they reflect national guidelines.

We carried out a desktop review of Severnbank Surgery on 24 June 2016 to ensure these changes had been implemented and that the service was meeting the regulations previously breached. For this reason we have only rated the location for the key question to which this related. This report should be read in conjunction with the full inspection report from 19 January 2016. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Severnbank Surgery on our website at www.cqc.org.uk.

We found the practice had made improvements since our last inspection on 19 January 2016 and they were meeting the regulations that had previously been breached.

Specifically the practice was operating safe systems in relation to emergency equipment and controlled medicines management. This included:

• The practice reviewed systems for checking and storing emergency medicines and equipment and had implemented new processes. The practice had replaced all the equipment previously noted to have been missing or out of date.
• The practice implemented a robust and consistent system for signing out dispensed controlled medicines. This was reflected by a policy amendment and discussed at a practice meeting.

We have changed the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well led services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as requires improvement overall. The practice was previously inspected in January 2016 and was rated as good overall and required improvement in the safe key question. A follow up desk based inspection was carried out in June 2016 and the practice was rated as good for providing safe services.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at Severnbank Surgery on 02 October 2018 as part of our inspection programme. We revisited the practice again on the 9 October 2018 to gather some additional information.

At this inspection we found:

• The practice had systems to manage risk so that safety incidents were less likely to happen. However, the system was not always clear and had not been applied consistently. When incidents did happen, the practice generally learned from them and improved their processes. However, there was no evidence that learning from incidents in the dispensary had led to improvements in systems and processes.
• Systems and processes for the safe management of medicines including emergency medicines held in the practice were not effective.
• There was a process for receiving medical and medicines safety alerts, however, there was not a recorded process and actions taken were not recorded.
• 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 able to access care when they needed it.
• Records relating to complaints were not always complete and complaints had not been analysed for trends and actions not taken to prevent the same things happening again.
• The practice had adopted policies and procedures; however, these were not personalised to ensure they were practice specific.
• There was focus on continuous learning and improvement at all levels of the organisation.

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

• Ensure care and treatment is provided in a safe way to patients.
• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Continue to improve the uptake for reviews of patients with long term conditions.
• Take action to ensure staff have received the appropriate immunisation.
• Record the system for the management of test results and the checking of staff registration.
• Identify ways to improve uptake for cervical screening.
• Improve engagement with the patient participation group so feedback is received and acted on.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups, it will be re-inspected no longer than six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

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