The Village Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

There was a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly in most cases, and lessons were learnt to identify and embed good practices. There were processes in place for managing emergencies and safety netting measures embedded in the triage system to manage clinical risk. Premises and equipment were managed safely with an overarching business continuity plan which had been recently tested for effectiveness. There were safe recruitment practices with a learning and development programme in place to support staff.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Healthwatch shared 2 patient comments with the CQC where patients had commented negatively about raising complaints. However, people had access to the practice complaints leaflet. This provided details of how to raise concerns both internally and externally and the action people could expect from the practice. The practice had analysed feedback from patients and identified that patients’ main concerns related to the need for more GPs, poor telephone access and the need for more available appointments. In response to this the practice recruited an additional 3 GPs, changed the telephone system and recruited more receptionists to answer the phones and extended the period of time patients could book appointments in advance. The practice had introduced a new telephony system with a queueing and call back facility allowing patients to maintain their place in the queue. The system also provided data on call waiting and dropped calls. The practice told feedback from patients had been positive about these changes. They shared these changes with patients though a You said, We Did board which was displayed at the entrance of the practice.

Leaders described to us the systems in place to involve and inform staff of learning from significant events and complaints. For example, following a problem receiving the results from bowel screening kits, administration staff developed a new system for tracking and chasing up any results they had not received. A lead GP told us that staff were encouraged to raise significant events within the practice and there were systems in place to support this. This was corroborated by both clinical and non-clinical staff we spoke to during our onsite assessment. We also collected feedback from staff through forms submitted to us during the assessment. Whilst most staff told us they did not attend meetings regarding significant events, and they were not involved in complaints investigations, they were aware of the process with minutes from the meetings shared with all staff. Feedback from the Integrated Care Board (ICB) showed there had been no significant incidents or complaints reported to them regarding The Village Surgery in the last 12 months.

There was a complaints policy and a significant events policy available within the practice and staff were aware of how to access these policies. Systems were in place to ensure complaints and significant events were investigated, responded to and any learning identified and shared. Tracking logs were maintained to record and monitor concerns and trends identified within the practice. The complaints and significant events we reviewed had been fully investigated and responded to appropriately and learning identified and shared with staff.

Results from the latest GP patient survey showed 94% of respondents felt the healthcare professional they saw had all the information they needed about them during their last general practice appointment, compared to the local and national average of 92%. 93% said they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment, compared to a local and national average of 92%.

The system to monitor referrals to other services, including 2 week wait referrals for potential cancer and following up on test results was effective. Feedback from staff supported this and staff were aware of their individual roles in assuring this happened. A clinician told us there was a system for following up on test results and this was effective. Clinicians referred patients to secondary care under the 2 week wait pathway for potential cancer. They told us they kept a record of the referrals they made and followed patients up if they had not received an outcome from the referral. They also informed patients to contact the practice if they had not received an appointment within 2 weeks of the referral. Receptionists we spoke with were aware of how to prioritise patients who reported symptoms that could be a clinical emergency. They had completed training in sepsis to support them in identifying patients potentially at risk of sepsis. Feedback forms from 11 members of staff showed that they were aware of their roles and responsibilities in supporting the safe care and treatment of patients. They told us there were systems in place to follow up patients that failed to attend appointments such as hospital appointments and immunisations.

We spoke with representatives of 3 care homes. They told us there was safety and continuity of care for people's stay at the home. People were regularly reviewed, including medicines reviews and health reviews. They told us a named GP actively reviewed people with DNARCPR plan in place together with the person if they had mental capacity and the family.

We reviewed the minutes from clinical meetings and found that the practice had identified an issue regarding the processing of urine samples. The practice reviewed their systems and made changes to their processes to ensure that urine samples were recorded, tested and that action was taken where required. They also introduced a tracking system to provide an audit trail and lines of accountability.

We did not gain any feedback from patients on safeguarding during our assessment.

Leaders discussed updates with staff and followed Derbyshire Safeguarding guidelines. They told us that there were dedicated leads within the practice that followed up children who failed to attend hospital. One of the GP partners told us that regular multidisciplinary meetings were held to discuss the care of children and vulnerable adults where there were known safeguarding concerns. They told us that when vulnerable adults and children were discussed, any changes in their care were recorded in their records. They told us that codes were added to the records of patients with a safeguarding concern and people living in the same household. Staff we spoke with, both clinical and non-clinical, were aware to the safeguarding policies, how to access them and the safeguarding lead for both adults and children. They shared examples of acting on concerns and action taken as a consequence. They had completed the appropriate level of safeguarding for their role, and were aware of the actions to take if they suspected or witnessed abuse and who the lead for safeguarding was within the practice. They carried out chaperoning duties and had received training to support them in this role and a Disclosure and Barring Service check. This was corroborated by 11 members of staff who completed feedback forms.

The local Integrated Care Board (ICB) had completed a joint safeguarding accountability and assurance framework for the practice to assess the effectiveness of the help provided to children and vulnerable adults. This showed that the practice was meeting the minimum required standards in safeguarding patients.

Policies to support staff in the safeguarding of children and vulnerable adults were in place and there was a system of review. There were named safeguarding leads within the practice and a system of identifying those patients with a safeguarding concern. We reviewed the minutes from clinical meetings and found that there were systems in place to review the care of vulnerable adults and children. The minutes also showed that systems were in place to follow up children that failed to attend for hospital appointments.

Data from the 2024 national GP patient survey showed that the percentage of respondents who stated that the last time they had a general practice appointment, the healthcare professional was good or very good at listening to them was 82%. This was below the local and national averages of 87%. Whilst his was below the local and national average, it had improved from a score of 68% in 2023.

Reception staff we spoke with were aware of where the emergency equipment and medicines were kept. They told us that a fire drill had been carried out in the spring to ensure that staff at the main practice were aware of procedures to follow in the event of a fire to keep patients safe.

We found that appropriate emergency equipment and medicines were kept at the practice and staff were aware of how to find these. We found that systems for checking emergency equipment and the expiry dates of medicines were effective.

Staff we spoke with told us they were trained in emergency procedures and were able to discuss the actions they would take if an emergency situation arose. We received staff feedback forms from 11 members of staff who told us they had appropriate equipment to carry out their role.

The surgery was located on ground level of the building and provided sufficient access. The premises was well maintained. Both the waiting room and reception area were well kept and clutter free. An all-access toilet and baby changing facilities were available and were to a good standard. The reception area overlooked the waiting room, allowing for clear monitoring of people sat there. Reception staff made an effort to ensure conversations were kept as private as possible.

There were systems in place to monitor the safety and maintenance of both premises. Risk assessments had been completed as required, and action plans developed to address any identified risks, although these were not always dated. Equipment had been tested and calibrated. Environmental risk assessments had been completed. Control of Substances Hazardous to Health Regulations (COSHH) data sheets were accessible to staff.

Most people we spoke with told us they were seen in a timely manner. They told us that there were enough qualified staff within the practice to meet their needs, and that the staff they saw were competent to carry out their roles.

Leaders told us that the practice had made the decision to become a more GP led practice. There were 3 GP partners and 5 salaried GPs within the practice, an increase of 3 salaried GPs since our previous inspection. The GPs had various skills and specialised knowledge to provide a range of care options for patients. They told us that the practice was exploring how they could integrate additional clinical roles, such as physiotherapists and clinical pharmacists, within the practice to support patients. Leaders told us the administrative team were recruited to the full complement and this had improved staff retention and morale. Staff we spoke with told us staffing levels had improved significantly in the GP team. However, nursing staff commented they would benefit from additional capacity to cover for sickness or holidays at both sites. Staff told us that they received annual appraisals or one to ones and that they felt supported in their roles. Whilst they were not always provided with dedicated time to complete required training, they fitted it in at training sessions and when they had gaps to do this. We received staff feedback forms from 11 members of staff who told us they had received a Disclosure and Barring Service check and their immunisation status had been checked as part of the recruitment process. Most staff members of staff told us there was adequate staffing levels within the practice to meet the needs of patients; some staff felt additional staff would support the practice through busy periods.

Policies and procedures were in place for the safe recruitment of staff. A screening and immunisation policy was in place and referenced the requirements as outlined in The Green Book. Systems were in place to provide assurance that staff recruited by the Primary Care Network and working within the practice were recruited and supervised appropriately. We reviewed the records of 4 members of staff recruited by the practice. We found that systems were now in place to ensure that all of the required recruitment information was in place. This included satisfactory written explanations of gaps in employment and an assessment of any physical or mental health conditions that were relevant to a person’s ability to work. The provider sent additional information following the assessment regarding risk assessments for staff who immunisation status was unknown. Risk assessments had been completed and extra precautions (use of personal protective equipment) worn in the interim until immunisation status was confirmed. Staff had completed training in line with the practice’s learning requirements and when updates were due, there was a system in place to inform staff.

People we spoke with found the surgery to be clean, tidy and well maintained. Some of them told us they observed clinicians wore gloves to examine them.

Staff we spoke with told us they had completed training in infection prevention and control (IPC) and they were aware of who the IPC lead was within the practice. They told us that the practice was spotless. Administrative staff were aware of actions to take to reduce the spread of infections. For example, they did not handle urine specimens and were aware of who they could go to for advice. This was corroborated by feedback forms completed by 11 members of staff. Nursing staff told us each staff member was responsible for maintaining their own electronic record for immunisations and vaccines. They told us risk assessments had been completed for staff who were not up to date with their measles, mumps and rubella (MMR) vaccine. Some staff told us cleaning standards at the branch site could be improved and this had been raised with management.

We reviewed consultation rooms on site which were found to be clean and tidy. Most surfaces were found to be wipeable except for some chairs used by clinical staff. There was appropriate personal protective equipment (PPE) available and hand washing facilities in place. Sharps bins were available in surgeries and used safely. Waste was stored securely and disposed of appropriately. We reviewed the records of 4 members of staff. In 3 of the records, we found that staff either had the required immunisations for the protection against health care acquired infections or risk assessments were in place to mitigate potential risks if an immunisation was not recorded. However, we found that there was no immunisation history for a clinical member of staff and a risk assessment had not been completed. This was sent to us following our onsite assessment.

There was a policy in place to support infection prevention and control. We reviewed the Infection, Prevention and Control (IPC) Audit. We found that the audit had failed to identify there were some non-wipeable chairs in consultation rooms. The provider immediately added this to their IPC audit. There was a clear action plan in place to identify any issues from the audit. Changes were implemented in accordance with the plan and evidenced positive improvement. For example, there was clear documentation of equipment being cleaned regularly and compliance with this was good. There was a clear system in place for waste disposal and collection. We saw evidence the cleaning team knew their role and responsibilities in relationship to maintaining communal areas. Cleaning schedules were in place and daily logs were completed.

The provider had gathered feedback from patients regarding medicines management through the Friends and Family test. There was one negative comment which related to needing to book a second appointment for a medicine review. However, 3 patients were positive about their medicine reviews and stated that staff were helpful, listened to them and there was a prompt follow up to any issues identified. One patient was positive about how quickly their prescription was available. The practice received 4 complaints in 2023 related to patients contacting the practice to chase up prescriptions they had requested but not received.

A lead GP described the process for managing patients who did not comply with reviews for medicines that required monitoring. They told us that after a consultation with the patient, a clinical risk assessment was completed to determine if they would continue to prescribe the medicine, reduce the number items per prescription or discontinue prescribing. This was done on an individual basis. They told us that they carried out Medicines and Healthcare products Regulatory Agency (MHRA) alert audits to monitor that the practice carried out care and treatment inline with these national alerts. An advanced nurse practitioner we spoke with was aware of the process for receiving and acting on Medicines and Healthcare products Regulatory Agency (MHRA) alerts. They told us that auditing of their prescribing and consultations was now in place and they received monthly clinical supervision to discuss the audits and learning from them. Feedback from the Integrated Care Board’s medicines management team was positive about processes monitored by them. They told us that the practice engaged positively with the team and responded to feedback and training provided to them.

Results from our remote clinical searches conducted as part of the assessment indicated that guidance in MHRA alerts was not always acted on. For example, MHRA alerts for medicines that could cause birth defects if taken during pregnancy had not always been followed. We found that annual risk assessment forms and pregnancy prevention plans were not available in the records of 4 out of the 6 records we looked at. The practice updated their policy and planned to implement monthly audits. However, we found that systems for prescribing medicines that required monitoring were effective. For example, medicines used in the treatment of rheumatoid arthritis. Medicine reviews were detailed and showed that required monitoring was up to date. Blank prescriptions were stored securely. There had been improvements in systems to monitor that prescriptions in printers were tracked in line with national guidance. However, only 4 out of the 6 boxes of prescriptions were recorded in the practice’s system. The provider added the missing boxes immediately and told us that they would arrange for the prescriptions to be returned due to their low usage. Following our assessment, the provider confirmed that a request to return the unopened boxes of prescriptions had been made. The practice could not be assured that vaccines were appropriately stored and monitored in line with UKHSA guidance to ensure they remained safe and effective. Records we saw demonstrated fridge temperatures were not always recorded daily, and on a number of occasions the temperature was out of range (at the branch site) and it was not clear if any action had been taken. The provider sent additional information following the assessment and told us they were purchasing a new data logger to assure themselves they could easily access required data on temperatures.

There were policies in place to support medicines management, including the management of vaccines. We saw that staff had the appropriate authorisations to administer medicines (including Patient Group Directions or Patient Specific Directions). We reviewed the prescribing of short acting inhalers for patients with asthma who had been prescribed 12 or more inhalers within the last 12 months. We found no harm to patients, however, there continued to be concerns regarding the processes for limiting the prescribing of these medicines to promote proactive rather than responsive management of their asthma.

National prescribing data showed that the practice was in line with local and national averages in the prescribing of antibiotics, pain killers such as pregabalin and medicines that cause changes in mood. The practice was below the local and national average in the prescribing of medicines that promote sleep which demonstrated they were proactive in monitoring the prescribing of these medicines to keep patients safe.