Cloister Road Surgery Also known as Drs Robinska,Sillitoe and Dhall

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions safe, effective, responsive and well-led. The rating for the key question caring would be carried through from the previous inspection. We carried out the previous inspection on 28 April 2016 and rated the practice as good overall.

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 good overall for all population groups, with the exception of f amilies, children and young people and working age people (including those recently retired and students) which are rated as requires improvement.

We rated the practice as r equires improvement for providing safe and effective services because:

• Blank prescription forms for use in printers and handwritten pads were not handled in accordance with national guidance.
• The practice’s uptake of the childhood immunisations rates was below the national averages for three out of four immunisations measured.
• The practice’s uptake of the national screening programme for cervical cancer was below the local and the national averages.
• Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses. When incidents did happen, the practice learned from them and improved their processes.
• Risks to patients were assessed and well managed.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided.
• Staff had the skills, knowledge and experience to deliver effective care and treatment.

We rated the practice as good for providing responsive and well-led services because:

• Feedback from patients reflected that they were able to access care and treatment in a timely way.
• The practice was encouraging patients to register for online services and 40% of patients were registered to use online Patient Access.
• The practice organised and delivered services to meet patients’ needs.
• Information about services and how to complain was available.
• The practice was aware of and complied with the requirements of the Duty of Candour.
• There was a clear leadership structure and staff felt supported by the management.
• The practice had demonstrated good governance in most areas, however, they were required to make further improvements.

We rated all population groups as good for providing responsive services. We rated all population groups as good for providing effective services, with the exception of families, children and young people and working age people (including those recently retired and students) which are rated as requires improvement, because of low childhood immunisations and cervical cancer screening rates.

The areas where the provider must make improvements are:

• 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:

• Keep fire safety processes under review.

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