Background to this inspection
Updated
28 April 2020
Summervale Surgery is based at Canal Way, Ilminster, Somerset TA19 9FE. We visited this location as part of our inspection. Further information about the practice can be found at .
The Partnership (Summervale Surgery) is registered with the CQC in respect of the regulated activities: Diagnostic and screening procedures; Family planning; Maternity and midwifery services; Surgical procedures and Treatment of disease, disorder or injury. They provide general medical services to approximately 7,579 patients. The practice is located in purpose built premises (2012) which it shares with another GP service.
The practice catchment area is situated within one of the least deprived areas of England ranking eight (with one being the most deprived and 10 the least) within The Index of Multiple Deprivation 2015 (The index is the official measure of relative deprivation for small areas in England). The practice age profile is mostly in line with local and national averages. Patients aged over 65 years of age are slightly higher than local averages at 27% (local 24% national 17%).
Since our previous inspection there had been changes to the partnership. One female partner has relinquished their partnership however they remain as a salaried GP and one female GP had retired. This meant four GP partners remained (all male). An additional GP Retainer worked at the practice.
The practice team includes an advanced nurse practitioner, a practice nurses and locum practice nurse, an emergency care practitioner, an interim practice manager, a finance and data manager, health care assistants, dispensary staff reception and administrative staff.
The practice is a training practice for post graduate medical students and doctors undertaking general practice speciality training. At the time of the inspection two GP registrars (a trainee GPs) were working at the practice.
The practice has opted out of providing Out Of Hours services to their own patients. Patients can access a local Out Of Hours GP service via NHS 111.
Updated
28 April 2020
We carried out an announced focused inspection at Summervale Surgery on 26 February 2020. Following our comprehensive inspection at Summervale Surgery (7 August 2019) the location was rated as inadequate with an inadequate rating for safe, effective and well-led and a good rating for caring and responsive.
Following this inspection (August 2019) we placed the service into special measures. The serious concerns were such that we took further steps to ensure the provider made changes to the governance of the service to reduce or eliminate the risks to patients. The provider was required to make improvements in respect of these specific deficits, as outlined in the warning notices.
We issued warning notices in regard to:
- Regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Good Governance
- Regulation 18(2) of the Health and Social Care Act (Regulated Activity) Regulations 2014, Staffing.
- Regulation 19(1)(2)(3) of the Health and Social Care Act (Regulated Activity) Regulations 2014, Fit and proper persons employed.
A focused follow up inspection was undertaken on the 27 November 2019 to check the progress the provider was making in regard to the regulatory breaches set out within the warning notices. At this inspection we found significant steps had been taken to address areas of concern. As a result we told the provider there were areas of the service where they needed to make improvements. We issued requirement notices:
- Ensure patients are protected from abuse and improper treatment
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
At this inspection (26 February 2020) we rated the practice as Good overall.
The key questions are rated as:
Are services safe? Good
Are services effective? Good
Are services caring? Good
Are services responsive? Good
Are services well-led? Good
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
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.
There were areas where the provider should:
- Have a process in place to regularly review the dispensary standard operating procedure (SOP) against national guidance.
- Consider an overarching document to access themes and trends for significant events and incidents.
- Continue to work towards the improving the quality of care for diabetic patients through appropriate monitoring and actions to reduce clinical complications.
- Continue to work towards completion of annual reviews for people living with mental health.
- Consider an overarching document to demonstrate the practice’s annual audit and quality improvement plan.
- Continue to work towards completion of annual appraisals in a timely manner.
- Record negative feedback from the Friends and Family Test within the overarching complaint log to allow for easy identification of themes and trends.
This service was placed in special measures in August 2019 in order for the provider to take steps to improve the quality of the services it provided. I am taking this service out of special measures. This recognizes the significant improvements 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 Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care