Background to this inspection
Updated
22 September 2023
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, treatment of disease, disorder or injury and surgical procedures.
The practice is situated within the Mid and South Essex Integrated Care System (ICS) and delivers General Medical Services to a patient population of about 6,900. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices called a primary care network, (PCN). This is called Canvey Island PCN and comprises 6 local GP practices.
Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 4th lowest decile (4 of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 0.8% Asian, 97.4% White, 0.8% Black, 0.9% Mixed, and 0.8% Other.
The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.
There is a team of 1 GP partner, 1 advanced clinical practitioner, and 1 muscular skeletal practitioner. The practice has a team of 2 nurse practitioners, 3 nurses and 2 healthcare practitioners. There is one pharmacist. The clinical staff are supported at the practice by a team of reception/administration staff. The practice manager and assistant practice manager provide managerial oversight.
The practice is open between 8 am to 6.30 pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.
Extended access is provided local practices, where late evening and weekend appointments are available. Out of hours services are provided by NHS 111.
Updated
22 September 2023
We carried out an announced comprehensive at The Island Surgery on 10 August 2023. Overall, the practice is rated as Good.
We rated the key questions:
Safe – Good
Effective- Good
Caring -Good
Responsive – Good
Well-led – Good
When this practice registered with us, it inherited the regulatory history and ratings of its predecessor. This is the first inspection at The Island Surgery under the new registered provider. When we inspected the previous provider in December 2017, the practice was rated Good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Island 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 for newly registered providers.
During this inspection we looked at the 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 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 short site visit.
- Face to face interviews with staff
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 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 dealt with 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.
- There was understanding, inclusive, and effective leadership at all levels.
- We found a strong collaboration, across the practice teams to support a common focus of improving the quality and sustainability of patients’ care and experiences.
- We saw governance procedures were proactively reviewed and reflected best practice.
- There was a demonstrated commitment to best practice performance, and risk management systems and processes.
- The practice reviewed and ensured that staff at all levels had the skills and knowledge to perform their roles effectively. We found when problems were identified they acted quickly, openly, and learned from them.
We found one area of outstanding practice:
- The practice had a designated lead for LBGTQ+ patients who had attended training and continually sought to keep up to date with best practice.
Whilst we found no breaches of regulations, the provider should:
- Continue to improve performance relating to prescribing of hypnotic medicines.
- Continue to improve the process for monitoring patients’ health in relation to the use of medicines.
- Maintain and monitor the system for recording and acting on safety alerts.
- Continue with measure to improve the uptake of the MMR vaccine and cervical screening.
- Continue to work to improve patient satisfaction with access to appointments.
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