Care Quality Commission Report

The Practice was inspected throughout the day on 14 January 2015 by the Care Quality Commission (CQC). The inspection team consisted of a CQC Lead Inspector, a GP, CQC Pharmacy Inspector and a Practice Manager; we received the draft report of their findings on 08 May 2015. They inspected the processes we follow, the service we provide to all our patients and the way in which we operate as an organisation.

We were inspected against the following criteria:

  • Are services safe?
  • Are services effective?
  • Are services caring?
  • Are services responsive to people’s needs?
  • Are services well-led?

There were a number of areas covered within each criterion and measured using the CQC’s own rating of ‘inadequate’, ‘requires improvement’, ‘good’ and ‘outstanding’.

The Practice received an overall ‘good’ rating with one area rated ‘requires improvement’ which applied to the safety of the storage of medicines. Listed below are the areas which the CQC rated as requiring improvement together with the actions the Practice are taking:

Area Highlighted by CQC

Action by Practice

Ensure medicine management systems are reviewed to ensure all medicines are kept securely and monitored appropriately

  • It was identified by the CQC that the doors marked ‘staff only’ should be locked. We will implement a locking system to these doors.

  • We will remove drugs from the emergency cupboard and store in another more secure location.

  • All Dosette boxes (compliance aid) are doubled checked by another member of staff.

Ensure emergency equipment checks are recorded to ensure equipment is maintained and checked at the correct intervals

  • We have a programme of maintenance and calibration which takes place annually for all our equipment. The CQC highlighted that whilst our emergency equipment is checked weekly, there was no written record of this. We will now implement the recording of these checks.

Ensure infection control audits are completed at appropriate timescales

  • We routinely carry out an annual infection control audit. With a recent change of staff, this had not been carried out in a timely manner and we are a few months late with the 2015 audit. This is now underway.

The CQC commented:

‘Specifically, we found the Practice to be good for providing well-led, effective, caring and responsive services. They were also good for providing services for all the population groups and had an outstanding element for how they treated patients with a learning disability. They required improvement for providing safe services particularly for the management of medicines’.

A full copy of the report can be downloaded from the link at the bottom of the page. You can also visit the Care Quality Commission’s website at

We would like to thank all our patients whom participated in questionnaires providing feedback on our services, the CQC received 156 completed questionnaire cards 151 had positive comments with only 5 negative comments about the service provided. Patients said they felt the Practice ‘offered an excellent service and staff were efficient, helpful and caring’. Other patients spoken with told the CQC that they were ‘satisfied with the care provided by the Practice and said their dignity and privacy was respected’.

Finally, as a Practice we continue to be very proud of the service we offer and the skills we have within our team. We will continue to provide the best service we possibly can to all our patients, carers and relatives.

Gayle Sykes
Practice Manager
June 2015

Mitcheldean Surgery Care Quality Commission Inspection Report June 2015