The Care Quality Commission
  • Doctor
  • GP practice

Archived: Clarence Park Surgery

Overall: Good read more about inspection ratings

13 Clarence Road East, Weston-super-mare, BS23 4BP (01934) 628111

Provided and run by:
The Locality Health Centre CIC

Important: The provider of this service changed. See old profile

All Inspections

2 April 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Clarence Park Surgery on 2 April 2019. This inspection was carried out to follow up on breaches of regulations and areas identified for improvement where we had rated the key question of well led as requires improvement. We had implemented one regulatory requirement, Regulation 17- Good governance and identified areas the provider should take action to improve.

This practice is rated as Good overall. (Previous rating November 2018 – Good)

Are services safe? – Good

Are services effective? – Good

Are services well led? – Good

The patient population groups were all rated as Good.

These were highlighted in the aspects of the areas of safe and well led:

The provider was required to:

  • Ensure patients with mental health needs and dementia had the necessary reviews and care plans in place to meet their needs, manage the risks associated with sepsis, including training for staff, the management of significant event management and complaints to monitor themes and trends.

We had also identified areas the provider should make improvements:

  • Central oversight of staff’ immunisation, change external security of clinical waste so that it could not be tampered with or removed from the premises.
  • Continue with an effective programme to ensure that patients with mental health needs and dementia have the necessary reviews and care to meet their needs.
  • The provider should continue with developing an effective monitoring system so that out of date information and instructions such as patient group directions for the provision of immunisations are removed and replaced when required.

At this inspection we reviewed the areas of safe and well led. We included effective as the information we had about the practice indicated potential changes and wished to assess this didn’t compromise meeting patient’s needs. We found:

  • A new system of assessment and management of health and safety had been implemented which needed to be fully embedded and sustained.
  • Improvements to seek information and confirmation of staff immunisation status was in progress but not yet completed.
  • Changes in some of the aspects of infection control had been implemented including security of clinical waste. However, infection control audits were not detailed and had not picked up issues such as appropriate storage of mops and disposable goods in line with current guidance.
  • The storage of medicines was not secure, such as clear stock monitoring and safe storage of medicines keys.
  • Staff had been trained to respond to medical emergencies – identifying patients at risk from sepsis.
  • The management and oversight of significant events and complaints had been strengthened with the improved recording and monitoring.
  • The new IT information management system had supported staff to maintain a clear oversight of risks, schedules and monitoring for areas including recruitment, employment and management of areas such as patient group directions for the delivery of vaccinations and immunisations.
  • There was an improved monitoring and a programme of support for patients with mental health needs and dementia.

The areas where the provider should make improvements are:

  • The provider should continue with developing a central oversight of staff immunisation status to ensure that staff and patients were protected from the spread of infection.
  • The provider should continue with a sustained effective programme to ensure that patients have the necessary reviews and care plans in place to meet their needs.
  • Ensure the new system of assessment and management of health and safety was embedded and sustained.
  • The oversight of infection control management and medicines should be reviewed to ensure it is secure and the system for monitoring medicine stock is improved.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

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

17/10/2018

During a routine inspection

This practice is rated as Good overall. (Previous rating under a different provider September 2015 – Good)

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? – Requires improvement

We carried out an announced comprehensive at Clarence Park Surgery on 17 October 2018 as part of our inspection programme.

At this inspection we found:

  • 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 a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

  • The provider must continue with the development of the overarching health and safety management including fire safety.
  • The provider must take measures to help manage the risks associated with sepsis - conducting staff training in recognising and responding to acutely unwell or deteriorating patients
  • The provider needs to continue to develop how it records significant event management and complaints to monitor themes and trends and to ensure that actions put in place are effective to prevent reoccurrence.

The areas where the provider should make improvements are:

  • The provider should continue with developing a central oversight of staff’s immunisation status to ensure that staff and patients were protected from the spread of infection.
  • The provider should continue with the changes put in place to the external security of clinical waste so that it could not be tampered with or removed from the premises by unauthorised people.
  • The provider should continue with an effective programme to ensure that patients with mental health needs and dementia have the necessary reviews and care plans in place to meet their needs.
  • The provider should continue with developing an effective monitoring system so that out of date information and instructions such as patient group directions for the provision of immunisations are removed and replaced when required.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

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