Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church Road Surgery on 25 August 2016. The overall rating for the practice was requires improvement. The practice was rated requires improvement for providing safe, effective and well-led services and good for providing caring and responsive services. This was specifically in relation to aspects of medicines management, risk management, quality monitoring and governance arrangements.

The full comprehensive report on the 25 August 2016 inspection can be found by selecting the ‘all reports’ link for Church Road Surgery on our website at www.cqc.org.uk.

An announced comprehensive inspection was undertaken on 26 September 2017.The practice was rated requires improvement for providing caring services and good for providing safe, effective, responsive andwell-led services. Overall the practice is now rated as good.

Our key findings were as follows:

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise most risks to patient safety.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Patient satisfaction survey information we reviewed showed patients felt the practice offered a good service and staff were helpful, friendly, attentive and polite and treated them with dignity and respect.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to make an appointment but not always a timely one with their preferred GP. Urgent appointments were available the same day.
• The practice had accessible facilities and was equipped to treat patients and meet their needs.
• There was a leadership structure and staff felt supported by management. The management team had been expanded to oversee specific areas of responsibility.

• The practice sought feedback from staff and patients and engaged with the patient participation group.

• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

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

The provider should:

• The practice should apply an effective induction programme with the inclusion of Infection and Prevention Control (IPC) training to support newly recruited members of staff and include this as part of mandatory refresh training.
• The practice should ensure consistent labelling of all sharps bin receptacles and review the environment cleaning schedule log to include cleaning tasks and frequency.
• The practice should continue to encourage the uptake of cervical screening.
• The practice should continue to encourage the uptake of childhood immunisations.
• The practice should review and implement ways to improve patient satisfaction with GP and nurse consultations.
• The practice should include information about the NHS independent advocacy service in its complaints procedure and information leaflets.
• The practice should consider the installation of an emergency call bell in the public toilet facility.
• The practice should consider formalising the strategy and supporting business plan. 

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church Road Surgery on 25 August 2016. Overall the practice is rated as requires improvement.

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.
• Although risks to patients who used services were assessed, some systems and processes to mitigate these risks were not implemented well enough to ensure patients were kept safe. For example, some aspects of infection and prevention control, medicines management, fire safety precautions, equipment safety and management of safety alerts.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• There was evidence of clinical audit but there were no full cycle clinical audits to demonstrate quality improvement.
• Patients said they felt the practice offered a good service and staff were polite, helpful, caring and treated them with dignity and respect.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and 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, however there was no hearing loop to assist patients with hearing impairment.
• There was a leadership structure in place and staff felt supported by management.
• The arrangements for governance and performance management were not always embedded or operated effectively. There was no consistent governance system in place to monitor the operations of the practice and to inform on required improvements.
• The practice sought feedback from patients which it reviewed and acted on where appropriate.

The areas where the provider must make improvement are:

• Ensure there are effective arrangements for the management of the vaccine cold chain, including staff training, so that appropriate actions are taken and documented where risks are identified.
• Ensure the security and tracking of all prescription stationery in line with national guidance.
• Establish effective methods for timely disposal of expired clinical apparatus.
• Ensure fire safety arrangements include a schedule of regular fire evacuation drills and internal fire alarm testing.
• Ensure all non-clinical staff undertake annual basic life support training in accordance with national guidance and that all recommended emergency medicines are available.
• Ensure there is an effective governance system of quality improvement including audit to assess, monitor and drive improved outcomes for patients.

The areas where the provider should make improvement are:

• Ensure there is an effective system that records the outcomes of actions taken in response to alerts issued by external agencies for example, the Medicines and Healthcare products Regulatory Agency (MHRA).
• Implement a schedule and log for the cleaning of non-disposable privacy curtains and review the arrangements for the disposal of sharps used to administer cytotoxic medicines.
• Review the list of clinical equipment used at the practice to ensure that they are all included in calibration checks.
• Carry out clinical audits including re-audits to ensure improvements have been achieved.
• Ensure all staff are made aware of the clinical code used to identify carers so that the appropriate support can be offered to them.
• Advertise the availability of translation services to patients and consider providing a hearing loop to support patients with hearing impairment.
• Consider a meeting forum for non-clinical staff to raise any issues and to receive relevant information formerly documented.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church Road Surgery on 26 September 2017. The overall rating for the practice was Good with Requires Improvement in Caring. The full comprehensive report on the 26 September 2017 inspection can be found by selecting the ‘all reports’ link for Church Road Surgery on our website at www.cqc.org.uk.

This inspection, on 25 October 2018, was an announced comprehensive inspection to confirm that the practice had carried out their plan to meet the requirements that we identified in our previous inspection on 26 September 2017. This report covers our findings in relation to those requirements and any improvements made since our last inspection. The practice is now rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

At this inspection we found:

• There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events. When incidents did happen, the practice learned from them and improved their processes.
• Clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.
• Some patient outcomes, for example, the childhood immunisation and cervical screening programme fell below national targets. However, we saw that some improvements had been made and the practice had plans in place to further address these shortfalls.
• Results from the national GP patient survey for some aspects of caring remained below local and national averages. However, the practice was taking steps to address this and patient feedback through comment cards was positive about care and involvement in decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of feedback.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients were able to make an appointment with a named GP and 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 provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvements are:

• Review the process to code vulnerable patients on the practice clinical system.
• Review best practice in relation to the recognition, diagnosis and early management of sepsis and consider if the practice can appropriately assess all patients, including children, with suspected sepsis.
• Review how patients are involved in care planning and care plan outcomes recorded.
• Continue to review ways to improve uptake rates for cervical screening and the childhood immunisation programme.
• Continue to evaluate patient satisfaction outcomes.
• Consider a system to alert patients when appointments are running late.
• Continue to review ways to encourage patients to engage with the practice through the Patient Participation Group (PPG) to help shape and improve services.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.