This practice is rated as Good overall. The practice was previously inspected on 28 September 2016 when it received a rating of good overall, but requires improvement for providing safe services. A focused follow up inspection was carried out on 24 May 2017, when the identified issues had been resolved, and the practice received a rating of good for providing safe services.

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 Undercliffe Surgery on 10 October 2018, as part of our inspection programme.

At this inspection we found:

• The practice significant incident reporting system was embedded throughout the practice. We saw that staff felt supported to report incidents; and that learning and improvements following incidents were disseminated to all staff.
• There were a number of practice specific policies and protocols which were regularly reviewed, and were accessible to all staff on the practice computer system.
• The practice carried out quality improvement activities which demonstrated improved patient outcomes. Care and treatment was delivered in line with current, evidence based guidance.
• We observed staff dealing with patients in a respectful and considerate manner. Feedback we received from patients confirmed this.
• National GP patient survey results, published in August 2018 showed a high level of patient satisfaction in relation to accessing the service, and in relation to the care and treatment they received.
• The practice had a strong focus on learning and development. Staff were supported to develop in key roles which supported new models of care delivery.

The areas where the provider should make improvements are:

• Maintain safe processes in relation to Disclosure and Barring Service (DBS) checks for new recruits, and for non-clinical staff undertaking chaperone duties.
• Continue to ensure that all staff receive safeguarding training and updates at the level appropriate to their role.
• Review staff immunisation status in line with Public Health England guidelines.

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 Undercliffe Surgery on 28 September 2016. The overall rating for the practice was good. However, a breach of legal requirements was found, resulting in a rating of requires improvement for the safe domain. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Undercliffe Surgery on our website at www.cqc.org.uk.

On 24 May 2017, we carried out this announced focused inspection. This was to confirm that the practice had carried out their plan to meet the legal requirements, in relation to the breaches in regulations that had been identified at our previous inspection on 28 September 2016. This report covers our findings in relation to those requirements and any additional improvements that have been made since our last inspection.

Our key findings were as follows:

• The practice no longer kept controlled drugs (CDs) on the premises. There was evidence that a risk assessment had been undertaken and that the CDs had been destroyed in line with guidance.
• There was a revised system and policy in place to recall and review those patients who were on medicines which required regular blood tests (such as warfarin) to ensure that dosages were adjusted accordingly.
• A system had been implemented to ensure that all Patient Group Directives (PGDs) were in date and signed.
• There were comprehensive records of when checks were carried out in relation to emergency equipment and medicines; including those kept in GPs’ bags.
• Checks of equipment and medicines held in the practice showed they were all in date.
• The practice had purchased new examination couches for the consulting rooms.

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 Undercliffe Surgery on 28 September 2016. Overall the practice is rated as good. The practice is rated as requires improvement for providing safe services.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• Not all risks to patients were assessed and well managed. For example, not all of the medicines and equipment we checked were in date. There was no process in place to ensure that patients taking warfarin medication had attended for testing or to check if their prescribed dose had been changed. The policies for controlled drugs were not being followed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• 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. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and there was 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.
• The patient participation group met regularly, carried out face to face patient surveys and spent time speaking to patients in the waiting room to encourage participation and find out their views.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The practice actively participated in local clinical commissioning group, GP practice cluster group meetings and federation meetings to discuss and plan future services for the locality.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

The provider must improve their approach to the proper and safe management of medicines. This includes by:

• Improving and implementing the procedures for obtaining, storing and checking all medicines including controlled drugs and medicines used in emergencies;
• Improving and implementing their repeat prescribing policy and the review of patients in relation to medicines, such as warfarin;
• Introducing and implementing an effective process to ensure that patient group directives (PGDs) are up to date.

The areas where the provider should make improvement are:

• Review the condition of their examination couches in clinical areas to assure themselves they are kept in a good state of repair.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice