The Care Quality Commission
  • Doctor
  • GP practice

Elm Hayes Surgery

Overall: Requires improvement read more about inspection ratings

Clandown Road, Paulton, Bristol, BS39 7SF (01761) 413155

Provided and run by:
Elm Hayes Surgery

All Inspections

26 May 2023

During an inspection looking at part of the service

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

2 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Elm Hayes Surgery on 2 November 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • The practice recognised the value of learning from significant events and had a system to review them regularly and as part of everyday practice. The practice carried out a thorough analysis of the significant events to look for root cause, ways to prevent any reoccurrence and identify any improvements needed. The significant events were a standing agenda item in meetings and learning was shared across the whole practice.

  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. The practice had supported many staff and provided training including National Vocational Qualifications (NVQ) in customer service and team leadership, NVQ in dispensing, practice managers diploma, NVQ in health care and diabetes and respiratory programmes.
  • The practice had a clear vision to provide patients with the traditional values of personal, high quality, patient focussed, responsive health care delivered from modern premises.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.

  • The practice had undertaken a number of analyses of the patient’s satisfaction and experience; they had looked at the difficulty with regards to patient telephone access, and implemented additional phones lines and advertised the benefit of online appointment booking to improve access.

  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. At Elm Hayes Surgery patients could access a number of services provided by other care providers including; counselling, audiology, podiatry, community paediatricians and a drugs and alcohol team.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice