The Care Quality Commission
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Farnham Dene Medical Practice

Overall: Good read more about inspection ratings

Farnham Centre For Health, Hale Road, Farnham, Surrey, GU9 9QS (01252) 730100

Provided and run by:
Farnham Dene Medical Practice

All Inspections

During an assessment under our new approach

Date of assessment: 6 to 9 August 2024 Farnham Dene Medical Practice is a NHS GP practice which provides primary care services to approximately 14,700 patients from 2 different sites in Farnham, Surrey. We carried out a responsive assessment and the reason for this assessment was due to concerns shared with the Care Quality Commission (CQC). We assessed 3 quality statements across the safe and well-led key questions and have combined the scores for these areas with scores from the last inspection. Following this assessment the practice is rated as good. At this assessment, we found safety was a priority for everyone and there was a culture of openness and collaboration. There were safe recruitment practices to make sure that all staff, were suitably experienced, competent and able to carry out their role. There were processes to ensure staff received effective support, supervision and development. There was an inclusive and positive culture within the practice and leaders proactively supported staff. Leaders were knowledgeable about issues and priorities for the quality of services and could access appropriate support and development in their role. Leaders actively encouraged staff to raise concerns and promoted the value of doing so.

28 June 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection of Farnham Dene Medical Practice, Farnham Centre for Health, Farnham, Surrey, GU9 9QS on 28 June 2016. The inspection was undertaken to check that the practice was making improvements following an inspection on 24 September 2015 where we found breaches in regulations relating to safe delivery of services. At the inspection on 24 September 2015, the practice was rated good overall and good for providing effective, caring, responsive and well-led services. The practice was rated as requires improvement for safe.

We found the practice had made improvements since our last inspection on 24 September 2015 and was meeting the regulations that had previously been breached.

Our key findings for this review were as follows:

  • The practice had reviewed and implemented changes to the recording of their cleaning schedule for equipment used.

  • The practice had ensured all Patient Group Directions (PDGs) had been signed by staff authorised to administer vaccines.

We have amended the rating for this practice to reflect these changes. The practice is now rated as good for the provision of safe, effective, caring, responsive and well-led services. The overall rating for the practice remains good.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

24 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Farnham Dene Medical Practice . Overall the practice is rated as Good.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • 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.
  • Urgent appointments were available on the day they were requested. However, some patients told us that they sometimes had to wait for non-urgent appointments. The practice had conducted patient surveys in relation to appointments and was investigating how it could improve its service to patients in this area.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management.
  • The practice proactively sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider must make improvements:

  • Ensure all staff working under Patient Group Directions (PGDs) are authorised to administer in line with national requirements (PGDs are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment).
  • Ensure that nurses have cleaning schedules in place for recording and signing when equipment is cleaned within treatment rooms.

Additionally the provider should:

  • Develop consistent systems to ensure that documentation is recorded, updated and stored effectively. For example, ensure that all training that staff have undertaken is recorded in the training log and the training schedule is updated, that complaints are centrally recorded and evidence of doctors GMC checks and indemnity insurance are correctly stored.

  • Ensure that a written policy is created for which staff are required a DBS Check

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

27 August 2014

During an inspection looking at part of the service

This was a follow up inspection to check the provider had taken the required actions to meet essential standards following our previous inspection in February 2014.

During this inspection we spoke with four staff members which included the practice manager, the practice nurse and reception staff.

People were protected from abuse through the provision of staff training, the presence of clear policies and the availability of information to staff and people who used the service.

The provider had taken steps to ensure that appropriate systems were in place to manage medicines. Records demonstrated that internal auditing to check the correct storage of medicines was carried out effectively.

Since our last inspection, the provider had taken some steps to improve their recruitment processes. However, the provider remained unable to demonstrate that all appropriate checks were made before staff began work.

We found the provider had taken steps to ensure that staff received regular appraisal. Staff we spoke with told us they felt well supported in their role. Effective arrangements were in place to ensure staff completed training appropriate to their role and to facilitate continuing learning and development.

10 February 2014

During a routine inspection

During our inspection of Farnham Dene Medical Practice we spoke with six staff, including GPs, nurses and reception staff. We also collected ten responses to a survey questionnaire we left in the patient waiting area.

People commented that they were treated with dignity and respect and that they felt involved in their treatment. One person commented 'I am always given information and choices regarding my care.' A second person commented 'The staff are always helpful and friendly.' People commented that the care they received at the surgery was good. One person commented 'The care I receive here is excellent.'

We found that whilst staff were aware of procedures around safeguarding children they were unsure about safeguarding vulnerable adults. Furthermore none of the staff had undertaken training regarding the protection of vulnerable adults. We found that the practice had good processes in place to manage infection control and all of the appropriate staff had undertaken training in this regard. People commented that the surgery was clean. One person commented 'It is a comfortable clean environment.'

There were no policies or procedures in place to manage the risks regarding medicines.

The staff recruitment practices were not robust and some staff had not had the required checks undertaken prior to or since starting work at the practice. The staff that we spoke with all felt supported. One member of staff said "100%!" However there were shortfalls in the supervision and appraisal processes and some health and safety training had not been provided.

There were clear procedures in place regarding complaints management and people felt their complaints were dealt with appropriately and in a timely manner. One person commented 'I complained once and it was responded to quickly.'