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The Care Quality Commission (CQC) carried out an inspection of Sutherland Lodge Surgery in December last year and its report published in May criticised the service provided by the practice. It received an overall rating of ‘inadequate’. Inspectors returned in January (three weeks later) and found we’d already made improvements, and the CQC published the report about these in June.

We were aware of, and were addressing, problems at the surgery before the CQC’s inspection and we have continued to implement a comprehensive action plan since, taking on board the inspectors’ feedback.

In the five months since the CQC last visited, the vast majority of changes they asked us to make have been implemented and, although there is more for us to do and we are committed to continuing to improve the practice, patients are already feeling improvements.

Based on the CQC report, we have detailed some of the improvement work we’ve done since December below.

Clinical governance

The CQC said we must ensure there are systems to assess, monitor, manage and mitigate risks to the health and safety of patients and establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

  • We have embedded a local clinical governance system in line with Virgin Care’s national clinical governance policy to address the concerns raised in the report
  • Includes processes which assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk


The CQC said we must ensure that the people providing care or treatment have the qualifications, competence, skills and experience to do so safely.

We have:

  • Carried out a comprehensive training review ensuring all colleagues have received appropriate training and inductions
  • Ensured that substantively employed staff have been and continue to be recruited in line with our Safer Employment Practices policy
  • Given locum and agency staff the appropriate support to ensure the quality of their work

Prescribing medicines

The CQC aid we must ensure the proper and safe management of prescribing medicines including repeat prescribing and monitoring of high-risk medicines.

  • We undertook a medicines safety audit in November 2017 and have completed the actions identified
  • We have ensured that colleagues understand the responsibilities of prescribing drugs which require monitoring under to the GMC’s ‘Good Medical Practice’ guidance
  • We carried out medicines and long-term condition reviews, recalling patients to the practice to review their current condition and ensure their treatment and medication was appropriate

Infection prevention

The CQC said we should ensure there were systems for assessing the risk of, and preventing, detecting and controlling the spread of infections.

  • We completed our annual infection prevention control audit in April 2018 have completed the resulting actions
  • We have an Infection Control Lead whose responsibility is to monitor the systems in place to ensure ongoing compliance, escalating any areas of immediate risk


The CQC said we should review the current processes to encourage patients to feedback on services, analyse the feedback and make improvements. We should  also actively seek the views of a wide range of stakeholders.


The CQC said we should ensure that equipment for providing care or treatment to a service user was safe and checks for out of date equipment should be made frequently

  • We carried out electrical testing (portable equipment testing), inspection and calibration on all equipment in use within the service by the end of May 2018 and a system is in place to ensure this is maintained
  • We have ensured that all staff are competent in their use of medical devices (such as emergency life support equipment) and receive training where necessary

Other improvements that have been made are –

Staffing levels

  • We are currently recruiting permanent GPs, advanced nurse practitioners and reception staff to fill a number of vacancies
  • Some of the GP hours are currently covered by locum GPs but where possible we use the services of long term locums to ensure continuity for patients

GP appointments

We offer:

  • More than the number of bookable appointments we are required to offer under our contract with the NHS every week
  • A fixed number of ‘book on the day’ GP appointments every day
  • A fixed number of urgent appointments a day with the duty GP
  • Appointments bookable up to four weeks in advance with a preferred GP
  • Access to the Duty Doctor for both telephone and face to face consultations from 08.30 – 18.30 Monday to Friday.
  • Online appointment booking (patients need to register for online services by filling in a registration form which they can pick up from the surgery)