Sunnyside Surgery

We carried out an announced inspection at Sunnyside Surgery on 15 March 2022. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Requires Improvement

This is the first inspection of this practice since a change in registration, during which the service changed address. At the last inspection, under the previous registration the practice was rated as good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Sunnyside Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

The CQC undertook this inspection at the same time as we inspected a range of urgent and emergency care services in Cornwall. To understand the experience of GP Providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

This inspection was a comprehensive inspection and included a site visit and remote searches of clinical records. We inspected the five key questions; is the service safe, effective, caring, responsive and well led.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A short site visit

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall.

We found that:

• Systems and processes for infection prevention and control (IPC) were followed to reduce the risk from infection. However, improvement and increased oversight was required for the safe management of clinical waste.
• Systems to assess, monitor and manage risks to patient safety were in place but not always effective or embedded. There had been insufficient oversight to ensure that the practice consistently followed their systems, practices and processes to keep people safe and safeguarded from abuse because Disclosure and Barring Service checks had not been completed for all staff prior to them working at the practice.
• The practice learned and made improvements when things went wrong.
• Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
• Staff had the information they needed to deliver safe care and treatment but the systems at the time of the inspection required formalising to reduce risk.
• The practice had not maintained oversight or carried out appropriate monitoring of patients to ensure the safe use of medicines, including medicines optimisation.
• The practice had a programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
• The practice was able to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
• Staff worked together and with other organisations to deliver effective care and treatment.
• Staff treated patients with kindness, respect and compassion.
• The practice organised and delivered services to meet patients’ needs.
• Although the practice had access to external organisations to support people whose first language was not English, not all staff had been made aware of these processes.
• Complaints were listened and responded to and used to improve the quality of care.
• There was compassionate, inclusive and effective leadership at all levels.
• The practice had regular business meetings to monitor their progress and delivery of services.
• The practice had not formalised a clear vision or values with the staff.
• There were clear responsibilities, roles and systems of accountability to support good governance and management. However, not all areas were regularly audited or monitored to ensure safe practice.
• The practice had processes for managing risks, issues and performance.
• The practice had systems in place to continue to deliver services, respond to risk and meet patients’ needs during the pandemic
• The practice involved the public, staff and external partners to sustain high quality and sustainable care.

We found one breach of regulations. The provider must:

• Establish systems and processes to ensure that any the risks relating to the health, safety and welfare of service users and others who may be at risk are monitored, mitigated and oversight maintained.

The provider should:

• Continue to monitor the system for summarisation of patient records so that the backlog is reduced within the planned timescale.
• Review the systems for patients to access the service. For example, for patients whose first language was not English or who had a sensory impairment.

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