Archived: Rowe Avenue Surgery

Letter from the Chief Inspector of General Practice

The practice was rated good overall and is now rated good for providing safe services.

We carried out an announced comprehensive inspection of this practice on 28 April 2016. A breach of legal requirements was found during that inspection within the safe domain. After the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the legal requirements. We conducted a focused inspection on 8 December 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.

During our previous inspection on 28 April 2016 we found the following areas where the practice must improve:

• Take action to address identified concerns with infection control.
• Ensure up to date risk assessments are undertaken in relation to fire and the safety of the premises.
• Ensure all necessary recruitment checks are undertaken for all staff.

Our previous report also highlighted the following areas where the practice should improve:

• Ensure that there is a clear audit trail in relation to the management of, and response to complaints.
• Ensure that significant event recording forms include details of where and when the event was discussed and shared with staff.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

During the inspection on 8 December 2016 we found:

• The practice had implemented cleaning schedules for all areas and that weekly checks of the environment and cleanliness were undertaken.
• An up to date fire risk assessment had been undertaken and remedial action had been taken where identified.
• Appropriate recruitment checks had been undertaken for all staff.

We also found in relation to the areas where the practice should improve:

• The practice had put in place a cover sheet for each complaint which enabled a clear audit trail in relation to receipt and responses to be recorded.
• Details of where and when significant events were shared and discussed with staff were now clearly recorded in the significant event form.

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 Rowe Avenue Surgery on 28 April 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were not always assessed and well managed. For example, the practice had not undertaken the necessary recruitment checks for all staff. There was no evidence that an up to date health and safety or fire risk assessment of the premises had been undertaken.
• Whilst the practice premises was observed to be clean, there were no cleaning schedules in place and not all waste was correctly stored.
• 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.
• Patients said they were treated with compassion, 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. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it was easy to make an appointment although not always with the same GP. Urgent appointments were available on the day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had implemented innovative approaches to staffing with the employment of a paramedic practitioner who was able to provide an on the day minor illness service and home visits to patients where it was deemed clinically appropriate.
• 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.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provide must make improvements are:

• Take action to address identified concerns with infection control.
• Ensure up to date risk assessments are undertaken in relation to fire and the safety of the premises.
• Ensure all necessary recruitment checks are undertaken for all staff.

The areas where the provider should make improvements:

• Ensure that there is a clear audit trail in relation to the management of, and response to complaints.
• Ensure that significant event recording forms include details of where and when the event was discussed and shared with staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice