We carried out an announced comprehensive inspection at Alma Road Surgery on 12 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:

• The practice could not provide us with the appropriate evidence to demonstrate GPs were appropriately trained in safeguarding children and vulnerable adults.
• The practice did not have appropriate systems in place for the security and monitoring of prescription stationery.
• Recruitment procedures were not consistently implemented.
• Limited oversight of the full loop closure of safety alerts.

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

• The practice could not provide adequate assurances that all GPs were appropriately trained in relation to Mental Capacity Act 2005 or Deprivation of Liberty Safeguards.
• The practice could not provide adequate assurances that all staff were appropriately training in relation to Information Governance.

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

• Systems and processes were not effectively established to ensure compliance with the requirements to demonstrate good governance. For example, there was a lack of oversight of GP training, prescription stationery security, safety alerts, and Disclosure and Barring Service checks.

We rated the practice as good for providing caring and responsive services because:

• The practice provided a personal named GP list system to promote consistency and continuity for its patients.
• 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.

These areas affected all population groups so we rated all population groups as requires improvement.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

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

The areas where the provider should make improvements are:

• Improve the identification of carers to enable this group of patients to access the care and support they need.

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 Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Alma Road Surgery on 18th November 2014. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services to all its patients in a safe environment. The practice is also rated as good for the six population groups which are older people, people with long term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

The practice was above average for its satisfaction scores on consultations with doctors and nurses with 98% of practice respondents saying the GP was good at listening to them and 96% saying the GP gave them enough time.

Data from the national patient survey showed 91% of practice respondents said the GP involved them in care decisions and 93% felt the GP was good at explaining treatment and results. Both these results were above average when compared to the CCG area.

Our key findings across all the areas we inspected were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• The practice delivered effective end of life care in line with the gold standards framework.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with their named GP and that there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The practice had a positive relationship with the patient reference group.

Area of outstanding practice:

• The practice had well developed systems for childrens safeguarding which was appropriately integrated with partner agencies to support the protection of vulnerable children and young people.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice