The Care Quality Commission
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Archived: Estover Surgery

Overall: Good read more about inspection ratings

Estover Health Centre, Leypark Walk, Estover, Plymouth, Devon, PL6 8UE (01752) 789030

Provided and run by:
Estover Surgery

All Inspections

09/08/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an inspection of Estover Surgery on the 9 August 2016. This review was performed to check on the progress of actions taken following an inspection we made on 4 November 2015. 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 9 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 11 February 2016. This can be done by selecting the 'all reports' link for Estover Health Centre 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 arrangements for managing medicines (vaccines).

  • Patient safety had been improved by introducing more robust recruitment checks of locum staff.

  • Improvements to records had improved patient safety. This had included ensuring the confidentiality of patient records, ensuring fire safety records were available and identifying a lead GP who would be responsible for safeguarding vulnerable patients at the practice.

  • Staff had received additional training to show they had the skills, knowledge and experience to deliver effective care and treatment.

  • 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

4 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Estover Surgery on 4 November 2015. 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.
  • 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.

The areas where the provider must make improvements are:

  • Extend Mental Capacity Act training to all clinical staff.
  • Consider patient records being accessed by unsupervised staff out of hours and the risk of breaches of confidentiality.
  • Establish a patient participation group.
  • Ensure checks for locum GP staff are consistently recorded.
  • Ensure there is monitoring to establish that appropriate action is taken when the cold storage of medicines temperatures exceed safe ranges.

In addition the provider should:

  • Clarify the identification of safeguarding lead clinician(s) in the practice.
  • Review the emergency call/panic button system and arrangements in the practice.
  • Establish a system for regularly reviewing fire system record keeping.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

9 January 2014

During a routine inspection

Estover Surgery had two partner GPs, one practice nurse, one healthcare assistant , four receptionists who also undertook administrative duties, and a practice manager. It had 2117 people registered as patients who received care and treatment including chronic disease management, child immunisation, travel vaccinations, phlebotomy (the process of taking blood), family planning and minor surgical procedures.

During our inspection people who used this service were asked to give us their feedback about this service either by email or by telephone. We received feedback from one person. The surgery did not have a patient participation group (PPG). Such a group would act as a voice for patients at the surgery. We spoke with one GP, the practice nurse, two receptionists and the practice manager.

We found practitioners gave people the opportunity to be involved in their own care and gave them information to help them make decisions made about their care and treatment. We saw this was recorded on the person's electronic patient record.

There were measures in place to check and protect the safety and wellbeing of children and adults registered with the practice and staff knew where to find the local safeguarding procedures.

We found the design and layout of the premises was not always suitable for staff working safely.

There were appropriate arrangements in place which ensured that staff kept their knowledge and skills up to date.

The practice was organised. There were effective systems in place to monitor the quality of the service provided.