Haverfield Surgery

We carried out an announced inspection at Haverfield Surgery on 6 July 2023. Overall, the practice is rated as good.

The key questions are rated as:

Safe - Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

When this service updated its registration details with us, it inherited the regulatory history and ratings from its previous location. We inspected the practice under the previous provider’s location on 28 April 2016 and the practice was rated as good overall.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

How we carried out the inspection/review

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 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 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 have rated the practice as Requires Improvement for providing safe services because:

The practice’s systems, practices and processes to keep people safe and safeguarded from harm were not always effective. For example:

• Not all staff were up-to-date with the practice’s mandatory training requirements and in line with national guidance, such as in safeguarding.
• Some actions and recommendations in the fire risk assessment dated 6 January 2023 had not been carried out.
• We saw that appropriate standards of cleanliness and hygiene were met. However, we found that there was no Control Of Substances Hazardous to Health (COSHH) risk assessment in place.
• Prescription stationery was not always been secured in line with guidance.
• There was an effective system for checking emergency equipment and medicines. However, we found that some blood test tubes were past their expiry date.

We also found that:

• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness, respect and compassion 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.

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

• Improve processes in place to ensure actions and recommendations from fire risk assessment are regularly reviewed and completed, in line with guidance.
• Embed identified improvements for infection prevention and control processes, secure storage of blank prescriptions and patients’ records and checking of blood test tubes, in line with guidance.
• Embed identified improvements in processes for assessing and monitoring patients and medicines, including long term conditions, child immunisations and Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions, in line with guidance.
• Improve processes in place to keep all staff up-to-date with the practice’s training requirements and develop systems in place to monitor and record staff training.
• Continue to make arrangements to keep all staff up-to-date with the practice’s appraisal requirements and develop systems in place to monitor and record staff appraisals.

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