The Care Quality Commission
  • Doctor
  • GP practice

Apsley Surgery

Overall: Good read more about inspection ratings

Cobridge Community Health Centre, Church Terrace, Stoke On Trent, Staffordshire, ST6 2JN 0300 790 0160

Provided and run by:
Apsley Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Apsley Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Apsley Surgery, you can give feedback on this service.

8 December 2022

During a routine inspection

We carried out an announced comprehensive at Apsley Surgery on 8 December 2022. Overall, the practice is rated as Good.

Safe - good

Effective -good

Caring - good

Responsive – good

Well-led -good

Our previous inspection on 12 August 2021, rated the practice as good overall and for all key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Apsley Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

Key questions inspected

  • We followed up areas including the ‘shoulds’ identified in previous inspection

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.
  • Staff feedback questionnaires

Our findings

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 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.
  • 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.

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

  • Maintain documentation to evidence when a locum staff member has a portable Disclosure and Barring Service (DBS) in place that this has been verified or checked prior to attendance.
  • Review staff vaccinations to be assured these are all maintained in line with current UK Health and Security Agency (UKHSA) guidance if relevant to role, and risk assess if unable to attend for a timely occupational health appointment.
  • Risk assess and follow up with the Community Health Partnerships building managers any adverse findings to the premises health and safety checks to ensure these are satisfactory.
  • Further improve documentation of mitigations of risk of reoccurrence for significant events and complaints as those verbalised by staff were more extensive than those documented
  • Implement further measures to continue to make improvements in the uptake of cervical screening and childhood immunisations.
  • Consider the implementation of a formal risk register and agree and document the practice strategic ambitions.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

12 August 2021

During a routine inspection

We carried out an announced inspection at Apsley Surgery on 12 August 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

After our previous inspection at Apsley Surgery on January 2021, the practice was rated Inadequate overall and for the Safe and Well Led domains, Caring was rated good and the Effective and Responsive domains rated as requires improvement. The service was placed into special measures. Services placed in special measures are inspected again within six months. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Apsley Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive follow-up with a site visit to for a service placed into special measures and to follow up on the breaches of regulations found at the last inspection in January 2021 at Apsley Surgery. The focus of inspection included:

  • Follow up of a Warning Notice breach in Regulation 17 HSCA (RA) Regulations 2014
  • Follow up on a Requirement Notice breach in Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment.
  • Four best practice recommendations

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspection differently.

This inspection was carried out in a way which enabled us to spend a shorter amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing remote clinical searches on the practice’s patient records system and discussing findings with the provider
  • Remotely reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A shorter site visit
  • Conducting remote discussions with the practice Patient Participation Group
  • Speaking with four staff who work within care home settings were residents receive a GP service from Apsley Surgery.

Our findings

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 with the exception of Families, children and young people which was rated as requires improvement.

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 adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. 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.

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

  • Continue to improve the carer register
  • Continue to improve cervical and cancer screening uptake
  • Consider measures to improve the uptake of childhood immunisations
  • Consider a review of the oxygen cylinder size at the branch site based on recent ambulance time to arrival
  • Gain advice on whether the use of the adult defibrillator pads are suitable for use on children if required
  • Lead GP to continue to progress the Care Quality Commission application to be the Registered Manager.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

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

18 January 2021

During a routine inspection

We carried out an announced comprehensive inspection at Apsley Surgery on 29 December 2020 with an on-site inspection on 18 January 2021 in response to a number of concerns raised with the Care Quality Commission (CQC).

This report was created as part of a pilot which considered innovative methods to fulfil CQC’s regulatory obligations and respond to risk in line with national guidance issued to promote safety during the COVID-19 pandemic. The inspection was carried out in line with CQC’s COVID-19 guidelines and was in part conducted remotely.

We undertook a remote clinical records review and a desk-based inspection which commenced on 29 December 2020 and completed a short on-site visit at the practice premises on 18 January 2021. As part of the desk-based inspection we spoke to staff including the Registered Manager the non-clinical partner and the Lead GP the clinical partner. We reviewed documentary evidence submitted by the practice.

The practice was previously inspected on 4 February 2020. The practice was rated requires Improvement overall and inadequate for providing Safe services. We rated each population group as good except for families, children and young people and working age people which we rated as Requires Improvement. We served a Warning Notice for breaches relating to Regulation 12 (Safe care and treatment). We found that improvements had been made in most but not all the areas identified in the Warning Notice. We also issued two Requirement Notices for breaches relating to Regulation 17(Good governance) and Regulation 19 (Fit and proper persons). We found that improvements had been made in most but not all the areas identified in the Requirement Notices.

Following this inspection, we have rated this practice as Inadequate overall and for the population group relating to people with long-term conditions. We served a Warning Notice for breaches relating to Regulation 17 (Good Governance).

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 found that improvements had been made in most but not all the areas identified in the inspection of February 2020 during this inspection.

The practice has been rated as Inadequate for providing Safe services because:

  • There was no specific induction tailored to the staff roles.
  • There were gaps found in the monitoring and management of medicines system.
  • The practice was not consistently following the significant event process as there were gaps seen in reporting and the documentation was lacking. Opportunities to raise, investigate and learn from events had been missed.

We rated the practice as Requires Improvement for providing Effective services because:

  • Cervical screening rates were below the national target.
  • The practice had not met the minimum 90% target for four out of the five childhood immunisation uptake indicators.
  • The Lead GP was solely responsible for the day to day monitoring of results referrals and patient clinical treatment and care for approximately 7,200 patients. The potential risk of a high workload includes the risk of error or omission and potentially on the health and wellbeing of the staff member.

We rated the practice as Good in providing Caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice as Requires Improvement for providing Responsive services because:

  • Opportunities to raise significant events and complaints had been missed.

We rated the practice as Inadequate for providing Well-Led services because:

  • Whilst the practice had made improvements since our previous inspection on 4 February 2020, it had not appropriately addressed all the areas documented in the Requirement Notice served for a breach of Regulation 17: Good Governance.
  • The practice culture did not effectively support high quality sustainable care.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.
  • The practice did not have an effective system to learn and make improvements when things went wrong.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Increase the identification of patients to the practice carer register
  • Explore and implement strategies to increase the uptake of childhood immunisations, breast and bowel cancer screening.
  • Review the effectiveness of strategies implemented to increase the uptake of cervical screening.
  • Support staff to understand the practice’s vision, values and strategy.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

4 February 2020

During a routine inspection

We previously carried out an announced, comprehensive of Apsley Surgery on 20 August 2015 and rated the practice as good overall and in all five key questions.

The full comprehensive report for the inspection in August 2015 can be found by selecting the ‘all reports’ link for Apsley Surgery on our website at www.cqc.org.uk.

We carried out an announced, comprehensive inspection at Apsley on 4 February 2020 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 requires improvement overall and in effective and well-led, inadequate in safe and good in effective and caring. We rated each population group as good except for families, children and young people and working age people which we rated as requires improvement.

We rated the practice as inadequate in safe because:

  • There were gaps in staff training. For example, safeguarding, fire safety and fire marshal.
  • All the required risk assessments had not been completed to mitigate potential risks.
  • Alerts had not been added to the records of the parents of a child with a child protection plan in place. The practice was unable to hold regular meetings with health and social care professionals, to protect vulnerable adults and children at risk of harm due to circumstances outside of their control.
  • All the required recruitment documents were not available for all members of staff employed by the practice. DBS checks or risk assessments to mitigate potential risks had not been completed for non-clinical staff particularly those who chaperoned.
  • A formal system of clinical review of the prescribing competence of three non-medical prescribers was not in place. However, following our inspection the practice forwarded to us evidence of how this would be completed.
  • Opportunities to raise significant events had been missed. A system for recording and reviewing significant events over time to identify trends was not in place.
  • Not all staff had received the immunisations appropriate to their role. Used sharp’s boxes had not been collected within three months after first use, even if not full.
  • Sharp’s boxes were not available at the branch practice.
  • The in-house fire risk assessment completed for the branch practice had failed to identify two risks.
  • Fire drills had not been carried out at the branch practice.
  • The legionella risk assessment for the branch practice showed there were 12 areas that need to be addressed. However, there was no evidence to demonstrate that 11 of these areas had been completed.
  • The system for tracking prescription stationery throughout the branch practice was not effective.
  • The practice did not hold all the suggested emergency medicines at the main or branch practice. Risk assessments for all the missing medicines had not been completed.
  • Oxygen, airway management equipment for children and a defibrillator were not available at the branch site. A risk assessment to mitigate potential risks to patients had not been completed.

We rated the practice as requires improvement in effective because:

  • The practice had not met the minimum 90% target for all four childhood immunisation uptake indicators. The uptake of the immunisation for haemophilus influenza type b and meningitis C booster was significantly below target.
  • Screening rates for breast cancer and bowel cancer were below local and national averages.
  • Cervical screening rates were significantly below the national target.

We rated the practice as good in caring because:

  • Staff treated patients with kindness, respect and compassion.
  • The practice respected patients’ privacy and dignity.

We rated the practice as good in responsive because:

  • The practice organised and delivered services to meet patients’ needs.
  • People were able to access care and treatment in a timely way.

We rated the practice as requires improvement in well-led because:

  • Systems for identifying, managing and mitigate risks were ineffective.
  • Governance meetings including clinicians had not been established.
  • An overarching system to review trends in significant events and complaints over time was not in place.
  • Staff did not know or understand the practice’s vision, values and strategy.

The areas where the provider must make improvements 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.
  • Ensure specified information is available regarding each person employed.

The areas where the provider should make improvements are:

  • Explore and implement strategies to increase the uptake of childhood immunisations, breast and bowel cancer screening.
  • Review the effectiveness of strategies implemented to increase the uptake of cervical screening.
  • Establish in-house safeguarding meetings to protect vulnerable adults and children.
  • Ensure information regarding how to complain is readily available for patients to access within the practice.
  • Support staff to understand the practice’s vision, values and strategy.

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

20 August 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Apsley Surgery on 20 August 2015. Overall the practice is rated as good.

Apsley Surgery also operates a branch surgery in the Norton area of Stoke on Trent. We did not inspect the branch surgery as part of this inspection.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients told us they could usually get an appointment when they needed one, although they may have to wait for a pre-bookable appointment with a specific GP. Urgent appointments were 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 practice proactively sought feedback from staff and patients, which it acted on.

There were areas of practice where the provider needs to make improvements.

The provider should:

  • Complete a practice specific fire risk assessment.
  • Record clinical audits in a way that clearly identifies the four stages of the audit cycle.
  • Complete training on the Mental Capacity Act and Children’s Act for all staff.
  • Ensure they always follow their own policy when dealing with complaints.
  • Consider developing a strategic plan to support the delivery of the practice values and any future developments.
  • Carry out a risk assessment to ensure the safety of confidential information within the practice.
  • Develop an action plan to address the issues identified in the national GP survey and Friends and Family Test.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice