Archived: Albion Street Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Albion Street Surgery on 17 December 2015. The practice was rated as requires improvement for safe and well led. The overall rating was requires improvement. Breaches of legal requirements were found.

Following on from the inspection the practice provided us with an action plan detailing the evidence of the actions they had taken to meet the legal requirements in relation to providing safe and well led services to the patients.  

We undertook a focused follow up inspection and visited the practice on 14 July 2016. This was to review in detail the information the practice had sent to us, observe the improvements made to the premises and to confirm that the practice were now meeting legal requirements. This report only covers our findings in relation to those legal requirements.

The full comprehensive report which followed the inspection in December 2015 can be found by selecting the 'all reports' link for Albion Street Surgery on our website at www.cqc.org.uk.

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

• Risks to patients were assessed and well managed. Risk assessments relating to health and safety, fire safety and COSHH (Control of Substances Hazardous to Health) had been undertaken. A fire alarm system, emergency lighting and exit signage had been installed. 
• The practice had a system to ensure patient safety alerts were received and acted upon. 
• Testing of the electrical hard wiring of the building had been undertaken and electrical fixtures had been replaced to meet modern standards.
• The practice manager and practice nurse were infection prevention and control leads. The practice had carried out IPC audits. Cleaning schedules had been introduced and were being followed.
• Clinical equipment was checked to ensure it was working properly.
• The practice carried out and documented actions such as flushing toilets and running taps in the disused bathroom which were necessary to prevent legionella contamination. Legionella is a term for a particular bacterium which can contaminate water systems in buildings.
• Staff had cleared the premises of inappropriate items and clutter had been removed.
• Practice specific policies were updated and were available to all staff.
• Effective arrangements had been made to identify, record and manage risks, issues and implement mitigating actions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice on our website at www.cqc.org.uk

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Albion Street Surgery on 17 December 2015. Overall the practice is rated as requires improvement.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses which were investigated and lessons shared.

• Patients were at an increased risk of harm because systems and processes were not in place to keep them safe. For example, appropriate risk assessments relating to health and safety, fire safety and COSHH (Control of Substances Hazardous to Health) had not been undertaken. Actions identified from an infection prevention and control audit had not been undertaken and documented. 
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity. They said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients. For example, the practice established arrangements so patients had access to a female GP and implemented a task noticeboard on the clinical record system to manage the demand for same day appointments.
• Urgent appointments were usually available on the day they were requested.
• The practice had a number of policies and procedures to govern activity, however some were overdue a review.
• There was a clear leadership structure and staff felt supported by management. However, there were limited formal governance arrangements and some members of staff said they were unsure how to access policies.
• The practice had proactively sought feedback from patients and were in the process of starting a patient participation group.

The areas where the provider must make improvements are:

• Take action to address and document identified concerns with infection prevention and control practice and operate a cleaning schedule appropriate to the care and treatment being delivered and monitor the level of cleanliness.
• Implement systems for assessing and monitoring Health and Safety, COSHH and fire safety risks and carry out actions identified in the legionella risk assessment.
• Provide staff with appropriate up to date policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.

The areas where the provider should make improvement are:

• Ensure there are systems and processes that assure compliance with relevant Patient Safety Alerts, recalls and rapid response reports regarding medicines that are issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS).
• Ensure that all equipment, such as blood pressure monitors, nebulisers and weighing scales are calibrated and safe for use.
• Ensure that a system is in place that assures the security and appropriate use of prescription pads.
• Ensure the practice works with the CCG to develop an action plan to address the outlying area of coronary heart disease.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice