The Care Quality Commission
  • Doctor
  • GP practice

Elm Surgery

Overall: Good read more about inspection ratings

123 Leypark Walk, Estover, Plymouth, Devon, PL6 8UF (01752) 776772

Provided and run by:
Elm Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Elm Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Elm Surgery, you can give feedback on this service.

28 September 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Elm Surgery on 28 September 2022. Overall, the practice is rated as good.

Safe – good,

Effective - good,

Caring - not inspected, rating of good carried forward from previous inspection,

Responsive - not inspected, rating of good carried forward from previous inspection,

Well-led – good.

Following our previous inspection in March 2016, the practice was rated good overall and for all key questions.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. The practice was chosen as a sample of good and outstanding services to confirm our direct monitoring approach.

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 patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short 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 and
  • information from the provider, patients, the public and other organisations.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Not all infection and prevention control processes were fully embedded into practice such as risk assessments and outcomes of actions.
  • Patients received effective care and treatment that met their needs.
  • Staff interacted with patients with kindness and respect.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The practice was resilient to challenges and continued to provide care and treatment to patients in a safe, effective and well-led way.
  • The practice were quick to respond to feedback implementing newly actioned processes following our inspection.

Whilst we found no breaches of regulations, the provider should:

  • Make sure there are appropriate Infection Prevention Control measures in place, including a regular audit and that all the action are completed as per timescales recognised in the audit.
  • Make sure all patients with long-term conditions and on high-risk medicines in need of regular reviews had those in place.
  • Improve cervical cancer screening uptake to make sure it meets the national targets.

We found the following areas of outstanding care:

The practice demonstrated resilience, as they have continued to provide safe, effective and well-led services throughout the COVID-19 pandemic and through the challenge of a growing practice population. This had increased from 6,000 to over 9,500 patients since the last inspection in 2016.

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

18/08/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an inspection of Elm Surgery on the 18 August 2016. This review was performed to check on the progress of actions taken following our inspection we made on 19 January 2016. Following that inspection the provider sent us an action plan which detailed the steps they would take to meet their breaches of regulation. During our latest inspection on 18 August 2016 we found the provider had made the necessary improvements.

This report covers our findings in relation to the requirements and should be read in conjunction with the report published on 10 March 2016. This can be done by selecting the 'all reports' link for Elm Surgery on our website at www.cqc.org.uk

Our key findings at this inspection were as follows:

  • The practice had improved the health and safety for patients by improving the governance processes. These were implemented to support effective monitoring and improvement of service quality; for example, infection control management, test result management and policy reviews.

  • The practice had gathered feedback from patients through the surveys and complaints received. The practice had begun to establish a patient participation group.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

19/01/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Elm Surgery on 19 January 2016. Overall the practice is rated as good. 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.
  • Risks to patients were assessed and well managed, with the exception of governance arrangements for the management of infection control and the system for reviewing tests results.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had 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.
  • 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.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. However, there was no hearing loop in place for those patients that were hard of hearing. The practice confirmed the day following the inspection that this had been ordered.
  • There was a clear leadership structure and staff felt supported by management.
  • A set of policies and procedures had been made available to staff online and in paper format, these were being developed further.
  • The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw several areas of outstanding practice:

  • The practice offered expertise in diabetes and personalised care for patients with other chronic diseases. For patients with diabetes they offered insulin conversion and adjustment as well as other medicines and rarely referred to the hospital services. Two nurses and one GP had developed particular skills in caring for patients with diabetes and had a good working relationship with two consultants specialising in diabetes at Derriford Hospital, allowing easy e-mail dialogue if problems arose. A number of the practices high risk diabetic patients had an element of shared hospital care. The practice had held a number of virtual diabetes clinics with consultants, to discuss some of the more complex diabetic patients. The practice was proactive by identifying patients with pre-diabetes and offered lifestyle advice to try to avoid progression to diabetes. They had currently identified around 200 patients with this diagnosis and were working with these patients to reduce risks to their health.

  • The practice identified patients who may be in need of extra support. 54 patients attended smoking cessation advice clinics and 34 patients stopped smoking (approximately 63%).

  • There was a system in place in the waiting room which enabled patients to alert reception staff that they wished to talk in private. This was done by just handing over a card that was available in reception and so allowing the patient complete discretion.

The areas where the provider must make improvement are:

  • Ensure governance processes are implemented to support effective monitoring and improvement of service quality; for example, infection control management, test result management and policy reviews.

In addition the provider should

  • Review processes in support of the development of a patient participation group.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice