We carried out an announced comprehensive inspection at Church Road Surgery on 26 September 2017. The overall rating for the practice was Good with Requires Improvement in Caring. The full comprehensive report on the 26 September 2017 inspection can be found by selecting the ‘all reports’ link for Church Road Surgery on our website at www.cqc.org.uk.
This inspection, on 25 October 2018, was an announced comprehensive inspection to confirm that the practice had carried out their plan to meet the requirements that we identified in our previous inspection on 26 September 2017. This report covers our findings in relation to those requirements and any improvements made since our last inspection. The practice is now rated as Good overall.
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? - Good
At this inspection we found:
- There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
- There was an open and transparent approach to safety and a system in place for reporting and recording significant events. When incidents did happen, the practice learned from them and improved their processes.
- Clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.
- Some patient outcomes, for example, the childhood immunisation and cervical screening programme fell below national targets. However, we saw that some improvements had been made and the practice had plans in place to further address these shortfalls.
- Results from the national GP patient survey for some aspects of caring remained below local and national averages. However, the practice was taking steps to address this and patient feedback through comment cards was positive about care and involvement in decisions about their treatment.
- Information about services and how to complain was available. Improvements were made to the quality of care as a result of feedback.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients were able to make an appointment with a named GP and there was continuity of care, with urgent appointments 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 provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
The areas where the provider should make improvements are:
- Review the process to code vulnerable patients on the practice clinical system.
- Review best practice in relation to the recognition, diagnosis and early management of sepsis and consider if the practice can appropriately assess all patients, including children, with suspected sepsis.
- Review how patients are involved in care planning and care plan outcomes recorded.
- Continue to review ways to improve uptake rates for cervical screening and the childhood immunisation programme.
- Continue to evaluate patient satisfaction outcomes.
- Consider a system to alert patients when appointments are running late.
- Continue to review ways to encourage patients to engage with the practice through the Patient Participation Group (PPG) to help shape and improve services.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.