We carried out an announced focused inspection at Glebe House Surgery on 6, 10 and 12 October 2022. Overall, the practice is rated as good.
The ratings for each key question are:
Safe - Good
Effective - Good
Caring – Not rated
Responsive – Not rated
Well-led - Good
Following our previous inspection on 5 November 2015, 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 Glebe House Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.
How we carried out the inspection/review
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
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 and obtaining feedback from staff using electronic questionnaires.
- 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.
- 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.
- There were adequate systems to assess, monitor and manage risks to patient safety with embedded systems in place to keep people safe and safeguarded from abuse.
- Patients received effective care and treatment that met their needs. The practice routinely reviewed the effectiveness and appropriateness of the care it provided. Regular multi-disciplinary working was evident.
- 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. There were high levels of satisfaction across all staff. Staff spoke highly of the culture and the compassion of leaders
- There was evidence of systems and processes for learning, continuous improvement and innovation.
Whilst we found no breaches of regulations, the provider should:
- Improve the system for gathering and maintaining a record of staff vaccinations.
- Take action to ensure all The Medicines and Healthcare products Regulatory Agency MHRA alerts are appropriately acted on.
- Take steps to review the backlog of patient records to be summarised and improve the system for overseeing this.
- Improve the process for reviewing, overseeing and auditing the nurse prescriber’s prescribing.
- Improve the oversight arrangements of practice audits.
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