This practice is rated as requires improvement overall. (Previous rating March 2018 – 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? - Requires improvement

We carried out an announced focused inspection carried out on 15 November 2018 to confirm that the practice had carried out actions to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 13 March 2018.

At the inspection on 15 November 2018 we found there were continuing shortfalls in the safe domain and service requirement notices in relation to: appropriate support, training, professional development, supervision and appraisal of staff employed by the practice.

We therefore carried out a full comprehensive short notice announced inspection on 23 November 2018, due to the concerns identified on 15 November 2018.

At this inspection we found:

• The practice managed risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However, this was not supported by suitable systems and processes to demonstrate that learning and improvements were embedded in practice and shared appropriately with relevant staff.
• There were shortfalls in the monitoring of prescription stationery.
• There were shortfalls in the management of risk from Legionella.
• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• The systems and processes in place for staff appraisals did not show that the practice policy had been consistently followed; and all staff had received appropriate supervision and appraisal.
• 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.
• Systems and processes to support the management and running of the practice were unclear and records were not consistently complete to enable the practice to show it was meeting the regulations at all times.

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
• Establish 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:

• Review arrangements for consultations with patients under the age of 16 years.
• Review arrangements for the safe monitoring and storage of emergency medicines.
• Review arrangements for identifying themes and trends from complaints and acting upon these.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

This practice is rated as Good overall.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection of Bury Road Surgery on 13 March 2018, as part of our CQC inspection programme.

At this inspection we found:

• The practice was supported by a proactive patient reference group who met three to four times a year and there was also a virtual representation of nearly 400 patients.
• Patient feedback on the day was mainly positive regarding all aspects of care provided by the practice.
• Appointment times had been extended from 10 to 15 minutes to allow for more time for GPs to address the needs of their patients appropriately.
• The practice had a designated lead for prescriptions and there were effective procedures to ensure all prescription requests, including medicine changes following hospital discharges, requests for repeat prescriptions or acute medicines requests were handled efficiently and in a timely manner.
• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• 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 not a clear training schedule or records of mandatory training and updates needed for all staff.

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

• 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.

The areas where the provider should make improvements are:

• Review how the practice is assured that all premises checks, electrical calibration testing dates and maintenance of equipment at the practice are in place
• Continue to promote an increased uptake of cervical screening to be in line with the national average.
• Review how all medicines stored at the practice are monitored including for the management of medicines expiry dates.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice