Emmett Carr Surgery

Background to this inspection

Updated 8 June 2017

Emmett Carr Surgery provides care to approximately 4,500 patients and is situated in north-east Derbyshire between the villages of Eckington and Barlborough. The main practice is situated in the village of Renishaw, and there is also a branch surgery approximately two miles away within Eckington Health Centre, Gosber Road, Eckington, Sheffield. S41 4BZ.

We visited the main practice at Renishaw during our inspection. The practice provides primary care medical services via a Personal Medical Services (PMS) contract commissioned by NHS England and NHS Hardwick Clinical Commissioning Group.

The registered patient population are predominantly of white British background. The practice age profile demonstrates slightly higher numbers of children and younger people and people aged 40-50 years old, whilst there are generally lower numbers of patients aged 65 and over in comparison to the local and national averages. The practice is ranked in the fourth least deprived decile and serves a mix of residential and semi-rural areas.

The main surgery operates from purpose built premises built in 1993, which is shared with the branch site of another local GP practice. All patient services are provided on the ground floor of the building, whilst the upper floor is used for administration.

The practice is run by a partnership of two full-time female GPs. The partners employ a practice nurse, a health care assistant, a phlebotomist and a care co-ordinator. The clinical team is supported by a practice manager with a team of nine administrative and reception staff, with some of these staff undertaking dual roles due to the nature of being a small practice. A self-employed advanced nurse practitioner works for two days on most weeks. A regular male locum GP also provides a session on Mondays.

The practice accommodates medical student placements from Sheffield University.

The main site opens from 8am to 6.30pm Monday to Friday. GP consultations commence each morning at Emmett Carr Surgery from 9am until 11am, and afternoon GP appointments are available from 3pm (from 2.40pm on Mondays) until 5.20pm.

Extended hours consultations are available to see the nurse on a Wednesday evening from 6.30pm until 7.30pm, and early morning GP surgeries are available from 7-8am each Wednesday. The practice closes on ten afternoons throughout the year at 1.30pm for staff training.

The branch surgery at Eckington opens from 8.30am to 6pm on Monday and Thursday and from 8.30am to 1pm on Tuesday, Wednesday and Friday.

The practice has opted out of providing out-of-hours services to its own patients. When the practice is closed patients are directed to Derbyshire Healthcare United via the 111 service.

Overall inspection

Good

Updated 8 June 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Emmett Carr Surgery on 8 November 2016. The overall rating for the practice was requires improvement. The full comprehensive report dated 8 November 2016 can be found by selecting the ‘all reports’ link for Emmett Carr Surgery on our website at www.cqc.org.uk.

We undertook an announced focused inspection on 8 May 2017 to confirm that Emmett Carr Surgery had carried out their plan, to meet the legal requirement in relation to the breach in regulation that we identified in our previous inspection. This report covers our findings in relation to the requirement and also additional improvements made since our last inspection.

.Overall the practice is now rated as good. Our key findings were as follows:

The practice had completed their action plan to meet the legal requirement.
The practice had adopted a more proactive approach to assessing and managing risks. For example robust procedures had been put in place for managing significant events and Medicines and Healthcare products Regulatory Agency (MHRA) alerts to ensure that all required actions had been completed, and that learning was shared with the practice team to prevent further incidents.
Recruitment processes had been strengthened to ensure that appropriate pre-employment checks were obtained for all staff, along with evidence of their immunity status.
The cleaning records had been updated to detail all tasks carried out and to show that regular spot checks were completed, to ensure that appropriate standards of cleanliness and hygiene were maintained.
The practice had strengthened the governance arrangements for overseeing the quality of care and to mitigate risks. For example the clinical audit system had been developed to include more full cycle audits to drive improvements in patient care.
The practice had established more formal meetings including regular clinical and business meetings, to aid communication, learning opportunities and improve the performance. All meetings were recorded to outline the issues discussed and responses and action points.
A succession plan had been put in place which set out the arrangements to cover unforeseen illness or departure of key members staff, to ensure continuity of care and the future security of the practice.

In addition the provider should:

Further review documentation relating to induction and the appraisal process to ensure staff receive appropriate training and development to carry out their work.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice