The Island Surgery

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