Elm Hayes Surgery

Updated 4 August 2023

Elm Hayes Surgery is located in Paulton at:

Clandown Road

Paulton

Bristol

BS39 7SF

The practice has a dispensary, which provided services to approximately 20% of the registered patient list, which was included as part of this inspection.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, and treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Bath and North East Somerset Integrated Care System (ICS) and delivers Personal Medical Services (PMS) to a patient population of about 9,000. This is part of a contract held with NHS England.

The practice is part of a wider network of 9 GP practices under Three Valleys Health Primary Care Network (PCN) serving approximately 68,000 patients in rural North East Somerset.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is the lowest decile (one 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 97.9% White, 1% Asian, 1% Mixed, and 0.1% Other.

The age distribution of the practice population closely mirrors the local and national averages.

There is a team of 8 GPs, of which, there are 4 partners and 4 salaried GPs. The practice has a team of 2 advanced nurse practitioners and 3 practice nurses who provide nurse led clinics for long-term conditions. The practice has a dispensary which has a team of a pharmacy technician, 2 dispensers and led by a dispensary lead. The GPs are supported at the practice by a team of 9 reception and administration staff. The practice manager and operations manager are based at the main location to provide managerial oversight.

The practice is open between 8am to 6pm Monday to Friday. The dispensary is open between 8:30am to 5:30pm. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally shared by the PCN, where late evening and weekend appointments are available. Out of hours services are provided by another provider, which patients can access via NHS111.

Updated 4 August 2023

We carried out an announced focused inspection at Elm Hayes Surgery on 24, 25 and 26 May 2023. Overall, the practice is rated as Requires Improvement.

Safe - Requires Improvement

Effective - Requires Improvement

Responsive - Good

Well-led - Requires Improvement

Following our previous inspection on 2 November 2016, 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 Elm Hayes Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out a focused inspection undertaking a site visit and remote clinical searches to review:

• Safe, Effective, Responsive and Well-led key questions
• Concerns in relation to patient access shared with CQC.

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.
• Staff feedback surveys.

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 that did not always keep patients safe. In particular, high-risk medicines were note always monitored and safety alerts were not appropriately actioned.
• Patients did not always receive effective care and treatment that met their needs. In particular, patients with long-term conditions were not always monitored in line with national guidance.
• Patients could access care and treatment in a timely way.
• Governance processes were in place but oversight of risk management for staffing was not always embedded. In particular, there were examples of staff lone-working, which increased the risk of incidents occurring due to the lack of support. Oversight of mandatory training was not effective to ensure all staff completed the required training.

We found breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Oversight of systems and processes must be established and operated effectively to ensure compliance with the requirements of the fundamental standards.

The provider should also:

• Improve the uptake of cervical cancer screening to eligible patients.
• Take steps to improve processes to monitor staff and patient feedback and learn from findings to improve their patients’ experience. For example, implement the plan to introduce a Patient Participation Group (PPG).

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