The Care Quality Commission
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Archived: Felmores Surgery

Overall: Good read more about inspection ratings

Felmores Surgery, Felmores End, Pitsea, Basildon, Essex, SS13 1PN (01268) 728142

Provided and run by:
Dr Jojo Mampilly

All Inspections

6 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a desk top review of Felmores Surgery on 6 October 2016. This was to check the practice had addressed areas for improvement highlighted during their earlier announced comprehensive inspection conducted on 8 June 2016. At this inspection the practice was rated as good overall, good for effective, caring, responsive and well led domains. The safe domain was rated as requires improvement.

During our last inspection we found the provider had not undertaken DBS checks for staff undertaking chaperone duties and did not have a risk assessment in place as to why one was unnecessary. The provider was asked to remedy these and a requirement notice for these improvements was issued.

The provider was also advised they should take action in the following areas;

  • Ensure the recording, analysis and actions for a significant event are fully documented and learning revisited ensure improvements have been maintained.
  • Ensure cleaning schedules can demonstrate the type and frequency of the cleaning required for the rooms and equipment.
  • Ensure clinical audits have sufficient narrative to identify learning and how this has been embedded to improve practice.
  • Ensure records of discussions, decisions and actions are appropriately documented and shared amongst the practice team. Actions should be revisited to ensure tasks are completed and learning embedded into practice. 

After the inspection report was published the provider sent us an action plan that detailed how they would make the necessary improvements. We were then provided with documentary evidence of the improvements they had made. We were able to carry out a desk top inspection without the need to visit the practice.

During this desk top inspection, we reviewed documents that demonstrated that all staff now had appropriate DBS checks in place including those required to undertake chaperone duties. We found their recording, investigation, analysis and sharing of learning had improved and had been documented. They had revised their cleaning schedules and provided a narrative analysis to their clinical data and how it had informed and improved clinical performance. 

We were satisfied that the practice had made the required improvements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

8 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Felmores surgery on 8 June 2016. Overall the practice is rated as good. Our key findings across all the areas we inspected were as follows:

  • The practice recognised, recorded, investigated, discussed and reflected on significant incidents as a practice team.
  • Medicine and patient alert information was appropriately actioned.
  • Staff had received appropriate training in safeguarding and followed up on non-attendance by children and vulnerable patients at clinical appointments.
  • The practice was clean and tidy and there was an appointed infection prevention control lead. However, the findings of their annual risk assessment were not reflected in their cleaning schedules to provide sufficient assurances.
  • The practice were conscientious regarding their management of medicines. They conducted regular medicine reviews and ensured the safe prescribing and monitoring of high risk medicines.
  • Data from the Quality and Outcomes Framework showed patient outcomes were at or above average for the locality and compared to the national average.
  • Staff worked within multidisciplinary teams to ensure the evolving needs of their patients were being met in a timely and appropriate manner.
  • Complaints information was available to patients. Staff supported patients raising concerns and were committed to resolving them as they arose.
  • The practice partners had a shared vision and strategy to prove consistent high quality care. They were visible and accessible for both staff and patients to speak with directly.
  • The practice had a number of policies and procedures to govern activity, these were routinely reviewed and accessible to staff.
  • Staff reported feeling valued, supported by colleagues and the practice management. They told us they enjoyed coming to work.

The area where the provider must make improvements;

  • Ensure all staff undertaking chaperone duties are DBS

    checked or have a risk assessment in place as to why one is unnecessary.

The areas where the provider should make improvement are:

  • Ensure the recording, analysis and actions from a significant event are fully documented and learning revisited to embed into practice.
  • Ensure cleaning schedules can demonstrate what, where, when and how individual rooms/equipment was cleaned.
  • Ensure clinical audits have sufficient narrative to easily identify learning and how this had been embedded to improve practice.
  • Ensure records of discussions, decisions and actions are appropriately documented and shared amongst the practice team. Actions should be revisited to ensure tasks are completed and learning embedded into practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During a check to make sure that the improvements required had been made

We asked the provider to send us an action plan on how the service would ensure that young people under 16 years of age could be seen by a clinician when not accompanied by a parent or guardian.

During this review we found that the provider had taken sufficient action to improve access to appointments with a clinician for unaccompanied young people under 16 years of age.

15 November 2013

During a routine inspection

During our inspection on 15 November 2013, we saw that the service was not accessible for children under 16 years of age unless they were accompanied by a parent or guardian.

We saw that staff spoke politely to people and consultations were carried out in private treatment rooms. People told us that staff always asked for their consent before they performed any treatment or procedure.

Information was clearly displayed for people, including health promotion, access to support services and information about the practice and the services provided. People told us that their treatment was clearly explained to them and they were able to ask questions and make choices.

The people we spoke with were happy with the service and did not have any concerns or issues about the care and treatment they received. There were adequate systems in place to ensure records were accurate and maintained.