We carried out an announced comprehensive inspection at Austen Road Surgery on 4 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 good overall and good for all population groups.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Risks were adequately managed and mitigating actions were in place. The practice had addressed previous concerns around health and safety, fire safety and the risk of legionella.
• Patients received effective care and treatment that met their needs.
• There was higher than average exception reporting in relation to mental health indicators.
• The practice monitored performance around patient outcomes and were in line with national and local averages in most areas. However, there was evidence on the day of inspection that not all patients were recalled for monitoring in a timely way.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice had improved access to training for staff and we saw evidence of a developing culture of learning.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• There was evidence of some quality improvements processes in place, however oversight and sharing of clinical audits and quality improvement activities was not comprehensive.
• Staff were positive about working in the practice and were supported in their roles.
• The practice had begun working on centralising staff vaccination records and were collecting information to ensure that all relevant staff were appropriately vaccinated.
• Minutes of meetings were not comprehensively recorded.

Whilst we found no breaches of regulations, the provider should:

• Review and improve how patients are recalled for annual reviews and monitoring of treatment.
• Coordinate clinical audits and quality improvement activities so that there is oversight and shared learning.
• Review exception reporting in relation to mental health indicators.
• Improve how meeting minutes are recorded.
• Continue to review the recording of staff vaccination in line with Public Health England guidance.

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

This practice is rated as requires improvement overall. (Previous rating October 2014 – Good)The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at Austen Road Surgery on 14 June 2018. The inspection was part of our planned inspection programme.

At this inspection we found:

• The practice did not have reliable systems in place to ensure prescriptions (pads and computer prescription paper) were kept securely and monitored.

• The assessment of risk at the practice had not been adequately managed and not everything that was reasonably practicable to mitigate risk had been undertaken. Areas including fire safety, legionella, electrical installation and health and safety were not adequate.The practice did not have adequate processes in place to learn from incidents and make improvements when things went wrong.

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

• There was an active patient participation group in place who told us that they had seen improvements within the practice.

• Staff were positive about working in the practice and felt valued and supported in their roles.

• Patient survey results were positive and higher than average in several areas.

The areas where the provider must make improvements as they are in breach of regulations are:

•Ensure care and treatment is provided in a safe way to patients.

•Ensure staff employed in the provision of regulated activities receive the appropriate training and professional development necessary to enable them to carry out their duties.

•Ensure that there are effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

•Take action to review their complaints procedure so that the information within the final response contains signposting information should the complainant remain dissatisfied and thus complies with the NHS complaints procedure.

•Take action to provide awareness training for all staff on the ‘red flag’ sepsis symptoms that might be reported by patients and how to respond appropriately.

Where a service is rated as inadequate for one of the five key questions or one of the six population groups, it will be re-inspected no longer than six months after the report is published. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group or overall, we will place the service into special measures. Being placed into special measures represents a decision by CQC that a service has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Austen Road Surgery was inspected on the 7 October 2014 as a comprehensive inspection.

We have rated the practice as good. The inspection team spoke with staff and patients and reviewed policies and procedures. Patient care was reviewed and communication with other services discussed. Safeguarding of children and vulnerable adults was understood and taken seriously by the practice. Their involvement of patients through the patient participation group was being developed. The practice’s ethos was to provide good patient care and to support and train staff to help provide this.

Our key findings were as follows:

• Patient feedback was positive regarding accessing appointments in a timely manner.
• Patient feedback was positive regarding staff. Including being treated with kindness and respect.
• The practice had infection control procedures in place and was seen to be clean and tidy.

• Staff were careful to maintain confidentiality of patient information.
• The practice had systems to keep patients safe including safeguarding procedures and means of sharing information about patients who were vulnerable

However, there were also areas of practice where the provider should make improvements.   

The provider should:

• Ensure the risk assessment for portable electrical equipment is recorded.

• The practice should ensure the chaperone policy defines the duties of staff when acting as chaperones

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced focused inspection at Austen Road Surgery on 5 December 2018.

At this inspection we followed up on breaches of regulations identified at our previous inspection in June 2018. The ratings remain unchanged from the June 2018 inspection as the purpose of this inspection was to review compliance against the warning notices issued.

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.

At this inspection we found, the practice had made significant improvements and was compliant with the warning notices, in particular:

• A system was in place to address health and safety within the practice including the risk of fire, control of substances hazardous to health (COSHH), electrical safety and legionella.
• A system was in place for security and monitoring of prescription forms.

• We saw evidence of significant events being analysed, reviewed and disseminated in the practice.
• Safety alerts were managed appropriately to ensure action was taken to protect patients from harm.
• We saw evidence that training for staff had been reviewed and was underway with the introduction of an online training system. However, this would take more time to demonstrate that this was embedded and there were significant areas that still required attention.

• The complaints procedures had been updated to ensure all final correspondence included signposting to the next steps if the complainant was unhappy with the response to their complaint.

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