The Care Quality Commission
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Archived: Emsworth Surgery

Overall: Good read more about inspection ratings

6 North Street, Emsworth, Hampshire, PO10 7DD (01243) 378812

Provided and run by:
Emsworth Medical Practice

All Inspections

24 June 2020

During an inspection looking at part of the service

We previously carried out an announced comprehensive inspection at Emsworth Surgery on 19 March 2019 as part of our inspection programme. We rated the practice as Good overall, however we found a breach of regulations and rated Safe as Requires Improvement. We also rated the provision of care and treatment for the population group people with Long-term Conditions as Requires Improvement. You can read the full report by selecting the ‘all reports’ link for Emsworth Surgery on our website at .

On 24 June 2020, we carried out a desk-based review to confirm that the practice had carried out its plan to meet the legal requirements in relation to the breach of regulations that we identified at our previous inspection in March 2019. This report covers our findings in relation to those requirements.

We found that the practice is now meeting those requirements and we have amended the rating for this practice accordingly. The practice is now rated Good for the provision of safe services. We previously rated the practice as Good for providing Effective, Caring, Responsive and Well Led services. The rating for providing care and treatment for people with Long-term Conditions has improved to Good.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we carried out our desk-based review
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated Safe as Good because:

  • The practice had implemented a protocol and procedure in place to ensure that all Patient Group Directions (PGDs) were appropriately authorised.
  • The practice had implemented a protocol and procedure in place to take appropriate action when fridge temperatures were recorded outside of the safe range.
  • The practice had implemented an appropriate security procedure to keep blank prescriptions safe from misuse.
  • The practice had ensured that clinical staff had received appropriate levels of safeguarding training.
  • Contaminated waste bins were locked and secured. The practice improved their infection control procedures in addition to the breach identified at the last inspection.

We rated the people with long-term conditions population group as Good because:

  • Exception reporting rates for long-term conditions had reduced since our last inspection in March 2019. Although rates were still high when compared to the CCG and England averages, the practice was able to provide appropriate clinical explanation for this.

The areas where the provider should make improvements are:

  • Continue to improve exception reporting rates (2020/21 personal care adjustment) for patients with asthma and Chronic obstructive pulmonary disease (COPD).

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 General Practice

19 March 2019

During a routine inspection

We carried out an announced comprehensive inspection at Emsworth Surgery on 19 March 2019 as part of our inspection programme.

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 have rated this practice as Good overall. However, we rated Safe as Requires Improvement.

We rated the practice as Requires Improvement for providing safe services because:

  • The practice did not ensure that all Patient Group Directions (PGDs) were appropriately authorised.
  • The practice did not take appropriate action when fridge temperatures were recorded outside of the safe range.
  • The practice did not have appropriate security to keep blank prescriptions safe from misuse.
  • Emergency medicines were not available for every expected eventuality.
  • Contaminated waste bins were locked but not secured.

We rated the following population groups as Good: people experiencing poor mental health, families, children and young people, people of working age, people whose circumstances make them vulnerable because:

  • Childhood immunisation uptake rates were in line with the World Health Organisation (WHO) targets.
  • The practice offered an extended hours service between 6.30pm and 7.30pm Monday to Thursday and between 7.30am and 8am Wednesday to Friday.
  • The practice had appointed clinical leads for patients with dementia, carers and those who were veterans.
  • Patients with a learning disability were visited in their own home rather than the practice to avoid distress.
  • The practice had reduced its use of antipsychotic medicines for patients with dementia by developing a ‘Challenging behaviour formulary.’ This had resulted in an audited reduction in their use and improved GP notes regarding discussion of risks and benefits of the use of antipsychotic medicines.
  • The practice worked with the PPG to reduce social isolation for elderly patients.

We rated the following population group as Requires Improvement: people with long term conditions, because:

  • Exception reporting rates for long term conditions were high compared to the CCG and England averages. Although they had reduced as evidenced in recent reports provided by the practice, they remained high.

We rated the practice as Good for providing effective, caring, responsive and well-led services because:

  • The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
  • People were able to access care and treatment in a timely way.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way for service users by ensuring the proper and safe management of medicines.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review systems for the safe storage of clinical waste.
  • The practice should have practice leaflets in other languages available in the waiting area.

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 General Practice

23 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Emsworth Surgery on 23 July 2015. Overall the practice is rated as good.

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Opportunity for learning from internal and external incidents and complaints was maximised.
  • The practice had systems in place to improve outcomes for patients. The practice had updated the practice computer system with the Ardens tools, which is a clinical safety tool that assists in safer prescribing of medicines, recalling patients for routine checks and included templates to assist in the recording and management of patients’ treatment to improve outcomes.
  • The practice had comprehensive systems in place to provide health promotion advice to patients, which included a quarterly newsletter and health education events at a local venue. The practice also referred patients to a lunch club that was organised by the patient participation group in order to reduce medical conditions associated with social isolation.
  • Patients indicated that they were happy with the care and treatment that they received at the practice and the national GP survey indicated that the practice score was in line with Clinical Commissioning Group averages and above national averages for the care provided by GPs and nurses.
  • Data for 2013 to 2014 indicated that the practice had achieved 93.85% of the total quality indicator points available compared to the national average of 94.2%

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

The provider should:

  • Routinely record reviews and actions taken as a result of significant events and complaints.
  • Ensure that the Health and Safety Policy has a date that it was written and a date for review. Also undertake and document health and safety audits.
  • Ensure that there is a programme for infection control audits to be completed every six months.
  • Ensure the disposal of all consumable stores that have passed their expiry date.
  • Update the practice information leaflet to ensure it includes correct information such as current opening times.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice