The Care Quality Commission
  • Doctor
  • GP practice

Glebe Surgery

Overall: Good read more about inspection ratings

The Glebe, Storrington, Pulborough, RH20 4FR (01903) 742942

Provided and run by:
Glebe Surgery

Important: This service was previously registered at a different address - see old profile

All Inspections

11 July to 13 July 2023

During a routine inspection

We carried out an announced comprehensive inspection at Glebe Surgery from 11 July 2023 to 13 July 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

We carried out an announced comprehensive inspection of Glebe Surgery in August 2022. At this inspection the practice was rated inadequate and placed in special measures. We issued two warning notices against Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance) because the quality of the care they were responsible for, fell below what is legally required.

This inspection in July 2023 was a comprehensive inspection to check the practice has made sufficient progress to improve. We also followed up on the warning notices. We found the practice had addressed all of our concerns and made significant improvements. The provider was compliant with the two warning notices and the rating has moved from inadequate to good.

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

Why we carried out this inspection

This inspection was carried out to confirm whether the provider continued to meet the legal requirements of regulations and to ensure enough improvements had been made in the areas identified at previous inspections.

The focus of our inspection included:

  • All key questions
  • To follow up on breaches of regulation 12 (safe care and treatment) and 17 (good governance)
  • Areas we said the provider should improve;
    -Take action to address the fire risk assessment by creating a documented action plan.
    -Improve the uptake of cervical screening.
    -Improve the systems for the identification of carers and ensure the information available allows carers to self-identify, to ensure all carers are provided with support.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews on site and using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A staff questionnaire.
  • A 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 found that:

  • The provider had made improvements and had fully addressed all the areas of concern raised by our last inspections.
  • Risks to patients, staff and visitors were assessed, monitored and managed effectively. This included child and adult safeguarding processes, staffing including recruitment and supervision, medicines management, health and safety, and information governance.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff treated patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
  • Staff told us they were happy with the level of support and communication provided by their management team.
  • The practice encouraged staff development and gave staff the opportunities to further their career.
  • The provider was fully engaged and committed to completing and embedding improvement actions. Governance systems and processes were improving, evolving, and embedding.

Whilst we found no breaches of regulations, the provider should:

  • Review systems and processes to improve uptake of cervical screening.
  • Provide formal training to non-clinical staff on sepsis and serious infection.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

13 September to 15 September 2022

During a routine inspection

We carried out an announced comprehensive inspection at Glebe Surgery between 13 and 15 September 2022. Overall, the practice is rated as inadequate.

Safe - inadequate

Effective - requires improvement

Caring - good

Responsive - good

Well-led – inadequate

Why we carried out this inspection

We carried out this inspection as part of our inspection programme. The practice re-registered with CQC on 24 March 2020 because they moved to a new location.

Our inspection included all key questions; safe, effective, caring, responsive, well-led.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews in person and using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A staff survey
  • 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 found that:

  • The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm.
  • Risks to patients, staff and visitors were not always assessed, monitored or managed in an effective manner. This included child and adult safeguarding processes, infection prevention and staffing including recruitment and supervision, medicines management, and information governance.
  • There was limited evidence to demonstrate that all incidents, concerns, or near misses were consistently recorded or that opportunities for learning and quality improvement were identified.
  • The responsibilities, roles and systems of accountability to support good governance and management were not always clear or effective.
  • Governance systems and processes were not established and operating effectively.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. They were a “COVID vaccination hub” for the local area and had carried out approximately 56,000 vaccinations.
  • Patients could access care and treatment in a timely way.
  • Staff told us they were happy with the level of support provided by their management team and each other. However, feedback was mixed about the communication within the practice and confidence that issues raised by staff would be addressed.
  • The practice hosted or delivered additional services; including that they were a veteran friendly practice, offered a GP chaplain service and hosted a supplementary wound clinic.

We found breaches of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Additionally, the provider should:

  • Take action to address the fire risk assessment by creating a documented action plan.
  • Improve the uptake of cervical screening.
  • Improve the systems for the identification of carers and ensure the information available allows carers to self-identify, to ensure all carers are provided with support.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services