The Care Quality Commission
  • Doctor
  • GP practice

Archived: Almondsbury Surgery

Overall: Good read more about inspection ratings

Sundays Hill, Almondsbury, Bristol, BS32 4DS (01454) 613161

Provided and run by:
Almondsbury Surgery

Important: The provider of this service changed. See new profile

All Inspections

7 July 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Almondsbury Surgery on 15 April 2015. Following our comprehensive inspection overall the practice was rated as good with requires improvement for the well- led domain. Following that inspection we issued a requirement notice. This notice was due to a breach of Regulation 17 of The Health and Social Care Act (Regulated Activity) Regulations 2014, Good Governance. The requirement notice was for the practice to ensure it evaluates and improves their practice in respect of the processing of the information particularly through monitoring performance through clinical audit cycles and ensuring policy and procedures were up to date with legislation and latest guidance. A copy of the report detailing our findings can be found at www.cqc.org.uk.

We undertook this focused inspection on 7 July 2016 to follow up the requirement and to assess if the practice had implemented the changes necessary to ensure patients who used the service were protected against the risks associated with no monitoring of the performance of the service.

We found that the provider had made the required improvements since our last inspection. Following this focused inspection we have rated the practice as good for providing a well led service. The overall rating for the practice is good.

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

  • Policies had been updated, reviewed and audited when required. Policies now contained detailed information to ensure staff followed correct procedures.

  • The practice was compliant with ‘The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance’.

  • Clinical audits undertaken by the practice evidenced the monitoring of quality systems and documented the actions taken by the practice when required. This evidenced the monitoring of quality systems and the practice had documented subsequent action.

  • Risks associated with the security of the premises had been assessed, actions had been taken and risks had been mitigated.

  • The practice had an active patient participation group (PPG) who work with the practice to improve services and the quality of care.

  • Complaints information for patients had been updated to include contacts for external organisations which allow patients to seek further advice should the practice’s response not be satisfactory.

  • Staff had received up to date training and appraisals. A schedule had been implemented to indicate when future training and appraisals were due to be completed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

15 April 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Almondsbury Surgery on 15 April 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring and responsive services. It was also good for providing services for all the population groups. They required improvement for providing well led services.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Staff had not always received training appropriate to their roles. Further training needs had been identified and planned.
  • 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.
  • 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.
  • 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.
  • Governance arrangements needed further attention including ensuring policies and procedures reflect current guidance and legislation, mandatory training was provided for all staff and ensuring regular clinical audit cycles were completed.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must

  • Ensure its governance systems and audits remain effective including regular clinical audit cycles and ensuring all policies and procedures were regularly updated and reflected current legislation and guidance including the infection control policy to ensure it met with ‘The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance’.

The provider should

  • Review its patient’s complaints information to ensure it included information on how a patient could refer their concerns or complaints to other agencies.
  • Ensure staff were trained at appropriate intervals for subject areas such as safeguarding vulnerable adults, infection control and fire safety.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice