20 March 2018
During a routine inspection
This practice is rated as Good overall. (Previous inspection 15 September and 3 October 2017 Requires Improvement )
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
We carried out an announced comprehensive inspection at Eldene Surgery on 20 March 2018. When we undertook a comprehensive inspection of Eldene Surgery in September 2017 we found areas of concern. The practice was rated as Good for Caring, and Requires Improvement for Safe, Effective, Responsive and Well led. The practice had submitted an action plan detailing the actions they were taking to meet legal requirements. All reports for the practice can be found by selecting the ‘all reports’ link for Eldene Surgery on our website at www.cqc.org.uk.
This report covers the comprehensive inspection we carried out at Eldene Surgery on 20 March 2018 to check whether the practice had completed the actions they told us they would take to comply with all regulations.
At this inspection we found:
- The practice had systems to manage risk so that safety incidents were less likely to happen.
- When incidents did happen, the practice learned from them and improved their processes.
- 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. The practice had a comprehensive programme of clinical audit which drove quality improvements.
- The practice had initiated a process whereby nurses attended peer review sessions with nurses from nearby practices. This enabled reflection and sharing of good practice to improve patient care.
- Comment cards received and patients spoken with, reflected that staff involved and treated patients with compassion, kindness, dignity and respect.
- The practice had taken actions to improve patient access, for example introducing additional telephone lines and employing additional staff.
The areas where the provider should make improvements are:
- Review systems and processes so that governance is consistently embedded and effective.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice