We carried out an announced comprehensive inspection at Abbey Court Medical Centre on 21 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 requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

• Patients were at risk as the proper and safe management of medicines was not being monitored appropriately.
• Records of the monitoring and review of patients prescribed high-risk medicines were not always appropriately documented.
• Infection prevention and control audits had failed to identify single use items that had passed their expiry date.
• The practice could not demonstrate that all staff had the required training in basic life support.

We rated the practice requires improvement for providing effective services because:

• Patient outcomes could not always be identified as not all audits were used to promote quality improvement.
• Staff were not monitored sufficiently to ensure they had appropriate training to carry out their roles.

We rated the practice as requires improvement for providing well-led services because:

• The practice could not demonstrate formal governance systems were effective, as they had failed to identify issues relating to safe medicines management, reviews and monitoring of patients prescribed high-risk medicines, infection prevention and control, staff training and audit activity to improve quality outcomes for patients.

The issues above affected all population groups so we rated all population groups as requires improvement.

We have rated this practice as good for providing caring and responsive services.

We found that:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are as follows:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure safe and proper management of medicines.
• Ensure that they assess the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated.
• Ensure systems and processes to ensure good governance are effective in accordance with the fundamental standards of care.
• Ensure staff employed by the service provider in the provision of a regulated activity receive appropriate training.

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

The areas where the provider the provider should make improvements:

• Continue to monitor the use of the newly established locum GP pack.
• Continue to monitor and improve the uptake rates for children aged 2 who receive immunisations.
• Improve responses to complaints made to ensure they include reference to the Parliamentary Health Service Ombudsmen.
• Continue to promote and implement an active patient participation group.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice