We carried out a review of the data available to us about Hazeldene House Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Hazeldene House Surgery, you can give feedback on this service.
We carried out an unannounced announced inspection at Hazeldene House Surgery on 9 December 2021. This inspection was focused on the management of access to appointments.
Overall, the practice remains rated as Good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Hazeldene House Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was undertaken in response to data we reviewed which suggested potential issues with access to appointments.
How we carried out the inspection
This inspection included a site visit. The lead inspector spoke with staff on site.
Interviews were carried out with the practice manger we also spoke with reception staff and observed patient experiences in booking appointments or attending the surgery.
We found that:
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
We carried out an announced comprehensive inspection at Hazeldene House Surgery on 19 September 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients.
Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
The practice had good facilities and was equipped to treat patients and meet their needs.
The practice had fully effective standard operating procedures and systems in the dispensary to govern dispensing activities.
Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. However, outcomes of significant events had not been shared with all staff or regular reviews carried out to identify trends.
Information about how to complain was not readily available although patients we spoke with told us they had not had cause to complain. Verbal complaints had not been documented to help identify any common trends.
Some arrangements were in place to ensure risks to patients were identified and managed.
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 areas where the practice should make improvements are:
Ensure outcomes of significant events are shared with all staff and carry out a regular analysis to identify any common trends, maximise learning and help mitigate further errors.
Ensure all risks to patients and staff are assessed and identified actions completed and the health and safety lead be provided with additional training appropriate to the role.
Ensure actions stated in the infection prevention control audit are completed or planned.
Record verbal complaints to enable trends to be identified.
Carry out health screening on new members of staff.
Review the competency of dispensing staff as part of their annual appraisal.
Consider increasing the number of nurse meetings held.
Chief Inspector of General Practice