We carried out an announced comprehensive inspection at Spring House Surgery on 15 May 2018. The overall rating for the practice was good with safe as requires improvement. The full comprehensive report for the May 2018 inspection can be found by selecting the ‘all reports’ link for Spring House Surgery on our website at www.cqc.org.uk.

This inspection was a desk based follow up inspection carried out on 12 December 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 15 May 2018. This report covers our findings in relation to those requirements.

The rating of requires improvement previously awarded for safe following our full comprehensive inspection in May 2018 is now improved to good.

Our key findings were as follows:

• Comprehensive risk assessments for health and safety, fire, legionella and infection control had been carried out.
• The practice had reviewed and updated its safeguarding policy for adults and children.
• A system for logging and monitoring the use of prescriptions had been introduced.
• A hearing loop had been purchased as part of the Accessible Information Standards.
• A matrix had been developed so that all staff training could be monitored.

• The area where the practice should make improvements are:

• Continue to complete the fire risk assessment action plan where issues were identified.

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

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

This practice is rated as Good overall. (Previous inspection December 2014 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

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 Spring House Surgery on 18 May 2018 as part of our inspection programme.

At this inspection we found:

• 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 patients 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.
• The practice offered extended hours to its patients.

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

• Establish effective systems and processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users

The areas where the provider should make improvements are:

• Improve its prescription security and introduce a log of prescriptions handed to GPs.
• Update safeguarding policies and review them regularly.
• Purchase a hearing loop as part of the Accessible Information Standards
• Keep an overview of training completed by staff to ensure that it was up to date.

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

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Spring House Surgery on 9 December 2014. We found that the practice was rated as good overall.

Our key findings were as follows:

• The practice is rated as good for safe. Staff understood their responsibilities to raise concerns, and report incidents and near misses. Lessons were learned and communicated widely to support improvement. Information about safety was recorded, monitored, appropriately reviewed and addressed. There were enough staff to keep people safe.

• The practice is rated as good for effective. National Institute for Health and Care Excellence (NICE) guidance was referenced and used routinely. Patient’s needs were assessed and care was planned and delivered in line with current legislation. This included the promotion of good health. Staff had received training appropriate to their roles and further training needs were identified and planned. The practice had an effective appraisal system in place for all staff. Multidisciplinary working was evidenced.

• The practice is rated as good for caring. Patients said they were treated with compassion, dignity and respect and they were involved in care and treatment decisions. Accessible information was provided to help patients understand the care available to them. We also saw that staff treated patients with kindness and respect ensuring confidentiality was maintained.

• The practice is rated as good for responsive. The practice reviewed the needs of their local population and engaged with the NHS Local Area Team (LAT) and Clinical Commissioning Group (CCG) to secure service improvements where these were identified. Patients reported good access to the practice and the GPs and 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 an accessible complaints system with evidence demonstrating that the practice responded quickly to issues raised.

• The practice is rated as good for well-led. The practice had a clear vision and strategy to deliver this. There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity. There were systems in place to monitor and improve quality and identify risk. The practice proactively sought feedback from staff and patients and this had been acted upon. The practice had a very active patient forum, several members of whom took time to speak with the inspection team. Staff had received inductions, regular performance reviews and attended staff meetings.

However there were areas of practice where:

The provider should:

• Minutes of meetings were not recorded in a consistent manner.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice