Archived: Eyam Surgery

We carried out an announced comprehensive at Eyam Surgery on 12 and 13 December 2022 and carried out our remotes searches on 9 December 2022. The practice is rated as good overall and in effective, caring, responsive and well-led and requires improvement in safe.

We inspected the previous provider of Eyam Surgery on 29 April 2021. At that inspection we rated the practice as good overall and in all key questions except for responsive which we rated as outstanding.

At the previous inspections on 29 April 2021 and 13 August 2019 we rated the practice as outstanding for providing responsive care because:

• The national GP patient survey demonstrated that patient satisfaction with access to appointments was above local and national averages.
• The practice had made changes to the practice in line with Accessible Information Standards.
• The practice had responded to the rural transport needs of their patients.

At this inspection, we found that those areas previously regarded as outstanding practice were now embedded throughout the majority of GP practices. While the provider had maintained this good practise, the threshold to achieve an outstanding rating had not been reached. The practice is therefore now rated good for providing responsive services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Eyam Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection due to a change of legal identity from a partnership to a single-handed GP practice on 20 October 2021. It was a comprehensive inspection to follow up on:

• The key questions safe, effective, caring, responsive and well-led.
• Three best practice recommendations made at our previous inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patients’ records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• An on-site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• What we found when we inspected.
• Information from our ongoing monitoring of data about services.
• Information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall.

We found that:

• Patients received effective care and treatment that met their needs.
• Patients with long-term conditions were reviewed in line with national guidance and patients were followed up appropriately. The practice had embraced local initiatives to support and improve outcomes for patients with long-term conditions.
• All nine indicators from The National GP Patient Survey for caring and access to appointments were above local and national indicators.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• There was a system in place for responding to and investigating complaints. However, patients were not always informed of their right to complaint to the Parliamentary Health Service Ombudsman when it was appropriate to do so.
• The practice provided a weekly, free of charge, bus service for patients living in rural areas to support them to access appointments at the practice.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

However, we rated the practice as requires improvement for providing safe care and treatment. This was because the practice had systems in place to provide care in a way that kept patients safe and protected them from avoidable harm. However, some of the systems were not always fully embedded into practice. In particular:

• Alerts were not added to the records of people living in the same household as a child with known safeguarding concerns.
• All of the required recruitment information was not available for some staff working at the practice.
• Legionella risk assessments had been completed however the provider was unable to demonstrate that the issues identified had been addressed.
• Fire drills had not been carried out at the branch practice.
• A formal system of audit and clinical supervision for non-clinical prescribers had not been carried out as identified as a best practice recommendation at our previous inspection in April 2021.

We found a breach of regulations. The provider must:

• Ensure specified information is available regarding each person employed.

In addition, the provider should:

• Add alerts to the records of people living in the same household as a child with known safeguarding concerns.
• Risk assess the frequency in which Disclosure and Barring Service checks should be reviewed.
• Embed into practice checks that professional registrations are in date for clinical staff working within the practice.
• Address issues identified in the legionella risk assessments.
• Carry out fire drills at the branch practice.
• Embed into practice the new policy to provide audit and clinical supervision for non-clinical prescribers.
• Adhere to their complaints policy and include details of the Parliamentary Health Service Ombudsman in response letters to people who have complained.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services