Background to this inspection
Updated
11 March 2019
Addiscombe Road Surgery provides primary medical services in 395a Addiscombe Road, Croydon CR0 7LJ to approximately 3,000 patients and is in Croydon Clinical Commissioning Group (CCG).
Northway Road Surgery is registered with CQC as a branch surgery. This is a newly modernised facility.
The clinical team at the surgery is made up of one part-time female lead GP, two part-time long-term male locum GPs and one part-time female practice nurse. The non-clinical practice team consists of a practice manager and five administrative or reception staff members.
The practice population is in the third less deprived decile in England. The practice population of children and working age people are below the CCG and national averages and the practice population of older people is above the CCG average and below the national average.
The practice is registered as an individual with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury.
Updated
11 March 2019
We carried out an announced comprehensive inspection at Addiscombe Road Surgery on 24 January 2019 as part of our inspection programme.
At the last inspection on 20 December 2017 we rated the practice as requires improvement for providing safe services because:
- there was not a clear system in place to manage safety alerts
- not all risks to patient safety from the premises had been adequately assessed and mitigated.
At this inspection, we found that the provider had satisfactorily addressed these areas.
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.
From the inspection in December 2017 and January 2019 we found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- 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 way the practice was led and managed promoted the delivery of high-quality, person-centre care.
When we inspected in December 2017 we identified some areas that were not breaches of regulations but where we recommended action. These were:
- Develop a system to receive, review and implement evidence based guidelines.
- Consider recording clinical discussions.
- Review processes for exception reporting for patients with long-term conditions.
- Review the process for obtaining consent for clinical procedures to include them being appropriately recorded.
- Improve access for patients who are disabled.
- Develop a system to record verbal complaints.
At this inspection we found that the practice had acted on all of the recommendations and most were completed. Work to improve access to reduce the rates of exception reporting was still ongoing. Although the overall rate of exception reporting had reduced, the rate of some indicators remained higher than average.
Access for patients with disabilities had improved, with the opening of a second surgery. The Addiscombe Road Surgery premises remained difficult for patients who used mobility aids to access. The practice told us of adjustments made for individual patients and of plans to ensure the practice operated only from suitable premises.
Whilst we found no breaches of regulations, the provider should continue to:
- Review processes for exception reporting for patients with long-term conditions.
- Continue to develop plans to ensure the practice operates only from suitable premises.
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