Background to this inspection
Updated
12 September 2019
Pond Tail Surgery provides general medical services to approximately 7,414 patients. The practice also provides care and treatment for the residents who are registered at the practice and who live in nearby care homes, which serve individuals with a diagnosis of dementia or who have nursing care needs.
Services are provided from Pond Tail Surgery, The Green, Godstone, Surrey, RH9 8DY.
There are two GP partners (one male, one female), two practice nurses and one phlebotomist. GPs and nurses are supported by the practice manager, and a team of reception/administration staff.
Data available to the Care Quality Commission (CQC) shows the number of patients from birth to 18 years old served by the practice is comparable to the national average. The number of patients aged 85 years and over is slightly above the national average. The percentage of registered patients suffering deprivation (affecting both adults and children) is slightly lower than the average for England.
Pond Tail Surgery is open from Monday to Friday between 8am and 6pm.
As part of a national initiative, GP practices in East Surrey offered additional routine and urgent GP appointments in the evenings and at the weekend for registered patients. These were available at designated practices or at Caterham Dene Hospital.
Appointments can be booked over the telephone, online or in person at the surgery. Patients are provided information on how to access an out of hour’s service by calling the surgery or viewing the practice website (www.pondtailsurgery.co.uk).
The practice offers a number of services for its patients including; sexual health advice and family planning, chronic disease management, minor surgery, smoking cessation, health checks and travel vaccines and advice.
Pond Tail Surgery is registered with the CQC to provide the regulated activities; Treatment of disease, disorder or injury; Surgical procedures; Diagnostic and screening procedures; Maternity and midwifery services and Family Planning
Updated
12 September 2019
We carried out an announced focused inspection at Pond Tail Surgery on 6 August 2019 as part of our inspection programme.
At the last inspection in June 2018 we rated the practice as requires improvement for providing safe services because:
- The practice did not always have reliable or effective systems to make sure that patients prescribed high risk medicines had regular and appropriate health monitoring and clinical review.
- Systems and processes were not always in place to monitor and follow up on concerns for patients at risk, including children who were not brought to their appointments.
- Safety alerts were not always documented, discussed and lessons learnt as a result.
We also found areas where the provider should make improvements:
- Strengthen the guidance provided for staff to include identification of symptoms for potentially seriously ill patients, such as sepsis.
- Continue to strengthen the systems used to record learning and share lessons, identified themes and action taken to improve safety in the practice as a result of significant events and complaints.
- Ensure all staff are aware of the practice vision and future planning in relation to their role, and that improvements and innovation within the practice are communicated to all staff.
- Review the arrangements in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
- Continue to monitor and take action where appropriate for areas with high exception reporting on Quality Outcomes Framework.
- Strengthen the programme of clinical audit and quality improvement activity, including to routinely review the effectiveness and appropriateness of the care provided.
We based our judgement of the quality of care at this service is 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.
Overall the practice continues to be rated as good and is now rated good for providing safe services.
Details of our findings
At this inspection we found:
- There was a process for monitoring patients’ health in relation to the use of medicines, including high risk medicines. We reviewed a sample of patients prescribed such medicines and saw their health was being monitored appropriately, prior to prescribing.
- The practice had processes in place to make sure vulnerable patients were monitored, and appropriate actions were completed as a result of any concerns.
- There were processes to identify, understand, monitor and address current and future risks including risks to patient safety. The practice fully recorded, investigated and acted on safety alerts. Actions were taken to improve safety and lessons were learned.
- The practice had resolved concerns relating to the guidance available to staff. Additional training was available to staff for identifying symptoms of serious infections.
- The practice demonstrated that significant events and complaints were thoroughly recorded, investigated and acted upon. All identified themes, lessons and action taken to improve safety in the practice was shared with all staff.
- Communication within the practice had improved and staff we spoke with were happy with the methods used to keep them up to date.
- There were arrangements in place to cover staff absences and busy periods.
- We found areas of high exception reporting and a lack of evidence to demonstrate quality improvement activity. The practice was experiencing staffing challenges which had impacted on their performance monitoring and improvement activity, including clinical audit.
The areas where the provider should make improvements are:
- Continue to monitor and take action where appropriate for areas with high exception reporting on Quality Outcomes Framework.
- Strengthen the programme of clinical audit and quality improvement activity, including to routinely review the effectiveness and appropriateness of the care provided.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.