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Archived: Downland Surgery

Overall: Good read more about inspection ratings

59 Tollers Lane, Coulsdon, Surrey, CR5 1BF (01737) 556880

Provided and run by:
Downland Surgery

All Inspections

10 July 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Downland Surgery on 15 November 2016. The practice was rated overall as good and requires improvement in safe. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Downland Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 10 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation 12 (1) and (2) Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014 that we identified in our previous inspection on 15 November 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

  • The practice had been taken over by a new provider since the last inspection and they were in the process of changing their registration with the CQC.
  • Risks to patients were assessed and well managed.
  • The practice updated its recruitment and selection policy to ensure references are obtained before recruiting new members of staff.
  • The practice introduced a confidentiality and security policy to ensure confidentiality agreements are in place for all members of staff.
  • The practice had made improvements to the patient toilet to make it accessible for disabled patients.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Ensure that a comprehensive legionella risk assessment is undertaken and that recommendations following the risk assessment are actioned.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

15 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Downland Surgery on 15 November 2016. 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.
  • Risks to patients were not always assessed and well managed.
  • 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.
  • 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.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

There were areas of practice where the provider must make improvements:

  • Ensure that all staff have child protection training relevant to their role.
  • Ensure that the practice has a defibrillator and medical oxygen available to respond to medical emergencies or to have completed a risk assessment identifying how they would deal with a range of medical emergencies.
  • Ensure that a comprehensive fire risk assessment is undertaken and that recommendations following the risk assessment are actioned.
  • Ensure written references are obtained before employing new staff.

There were areas of practice where the provider should make improvements:

  • Ensure that a comprehensive legionella risk assessment is undertaken and that recommendations following the risk assessment are actioned. 
  • Review practice procedures to ensure confidentiality agreements are in place for all members of practice staff.
  • Review practice procedures to ensure clinical equipment are checked yearly as required.
  • Ensure accessibility in the patient toilet is improved.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice