The Care Quality Commission
  • Doctor
  • GP practice

Vista Road Surgery

Overall: Good read more about inspection ratings

Vista Road, Newton Le Willows, Merseyside, WA12 9ED (01925) 221457

Provided and run by:
Market Street Surgery

Important: This service was previously registered at a different address - see old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Vista Road 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 Vista Road Surgery, you can give feedback on this service.

Not Applicable

During an inspection looking at part of the service

At our previous follow-up inspection of the safe domain for Vista Road Surgery on 12 December 2019, the practice was rated requires improvement. On 8 July 2021 we carried out an announced desktop review of The Vista Road Surgery to assess compliance with the breaches found at that time and we have rated the safe domain as good

Overall, the practice remained rated as Good.

The rating for the key question followed up was:

Safe - Good

The other key questions remain unchanged and are rated as Good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Vista Road Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focussed review of information we hold and did not involve a site visit. This was to follow up on the key question – Are the services at this location Safe.

We reviewed the breaches identified at the last inspection of Regulation 12 HSCA (RA) Regulations 2014 Safe Care and treatment. The regulation was not being met because:

  • The provider had not identified the need to act to make sure the hot water system was cleaned and chlorinated in line with the recommendations from the legionella report completed December 2018.
  • The provider had not ensured guidance and systems for handling letters from secondary services were clear or put a failsafe in place to ensure these were always dealt with appropriately.
  • The provider did not have effective arrangements in place for the monitoring and security of prescriptions pads and computer prescription paper, both on delivery and when they were distributed through the practice.
  • The provider had not completed a risk assessment to identify mitigating steps needed regarding medicines or other items omitted from the emergency medicines and equipment kit.
  • The provider had not ensured all equipment provided for emergency response is clean and fit for purpose
  • The provider had not ensured documents that gave nurses permission to administer prescription-only medicines were completed properly and legally.

We reviewed breaches identified at the last inspection of Regulations 19 HSCA (RA) Regulations 2014 Fit and proper persons employed. The regulation was not being met because:

  • Disclosure and barring checks (DBS) had not been completed for recently employed staff.
  • A risk assessment had not been completed to identify and mitigate potential risks.
  • Systems were not in place to support the completion of these checks before staff took up their posts.
  • A health declaration which confirmed fitness for the role had not been sought from the most recent recruit.
  • Information to confirm the immunisation status of staff was not readily available.
  • Systems were not in place to support the completion of these checks before staff took up their posts.

We also reviewed the areas where we recommended that the provider should make improvements:

  • Consider measures to prevent accidental power loss to the vaccination fridge that is not hard wired.
  • Consider displaying the cleaning rota in each room. Review the cleaning schedule for the consultation room used for minor surgery room.

How we carried out the review

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

This review was carried out without visiting the practice. 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
  • Requesting evidence from the provider
  • Reviewing action plans sent to us by the provider

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found from the documents the practice submitted and from our interviews with staff
  • 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.

We found from the documents submitted that:

The breaches of regulation 12 HSCA had been addressed:

  • Action had been taken to ensure the hot water system was safe and complied with all legionella water safety requirements;
  • prescription pads were stored securely;
  • the contents of emergency response kits had been risk assessed;
  • we saw records that showed the emergency response medicines and equipment were clean and well maintained;
  • non-medical prescribers were correctly authorised to administer prescription only medicines legally;
  • systems had been introduced to ensure letters from secondary care were dealt with efficiently and actioned as required.

The breach of regulation 19 HSCA (RA) had been addressed to ensure that all the information specified in Schedule 3 HSCA was readily available for each person employed. Evidence of pre-employment health checks and ongoing checks of professional registration were provided.

We found that the provider responded to the ‘shoulds’ that were identified at the previous inspection.

  • The provider had taken effective steps to prevent accidental power loss to the vaccination fridge as it had now been hardwired in order to prevent accidental switch-off.
  • The provider had ensured cleaning rotas were placed in all rooms. These were monitored to ensure the cleaning regimes were followed.

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

During an inspection looking at part of the service

We carried out this announced focussed inspection at Vista Road Surgery on 12 December 2019 to, follow-up on Requirement Notices made in the safe domain at the previous inspection on 7 November 2018.

We looked at the key question: safe.

At the last inspection in November 2018 we rated the practice as requires improvement for providing safe services because:

  • Systems in place did not ensure patients on high risk medicines were appropriately managed.
  • Emergency medicines provided at the main branch and carried in the doctors’ bags did not meet best practice and emergency equipment was out of date.
  • Systems in place did not ensure infection prevention and control measures met legal requirements.

While the practice had made some improvements since our inspection on 7 November 2018, the Requirement Notice in relation to emergency medicines and equipment available at the main practice and carried in the doctors’ bags had not been fully addressed. In addition, infection control requirements had not been fully met.

At this inspection we also identified additional concerns that put patients at risk in particular: the management of patient group directives which are, signed documents permitting nurses to administer certain medicines, did not meet the legal requirements; recruitment policies and procedures were not followed to ensure all the required information was checked before new recruits commenced work in particular: disclosure and barring service (DBS) checks and pre-employment health checks; and appropriate information about the immunisation status of staff was not readily available.

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.

The practice continues to be rated as requires improvement for providing safe services because:

  • The practice did not provide care in a way that kept patients safe and protected them from avoidable harm.

We carried forward the ratings from the last inspection for all other key questions and all population groups which all remain rated as good. The overall rating remained good.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

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

The areas where the provider should make improvements are:

  • Consider measures to prevent accidental power-loss to the vaccination fridge that is not hard wired.
  • Consider displaying the cleaning rota in each room. Review the cleaning schedule for the consultation room used for minor surgery room.
  • Consider policies and procedures to reduce any risks associated with online services.
  • Consider introducing processes that audit the management of information about changes to a patient’s medicines and other care and treatment made by other services.

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

7 November 2018

During a routine inspection

This practice is rated as Good overall. The practice changed its main location in March 2017 and this is the first inspection since that change.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Vista Road Surgery on 07 November 2018. This was a part of our inspection program.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • There were effective methods of engaging with the community projects and the public.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • There was a clear leadership structure and staff felt supported by management.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • Patients found they could access routine and urgent appointments, however patients stated they had to wait a long time to see the clinician of their choice.
  • There were gaps in some aspects of medicines management.
  • Paper records were not always stored completely in line with personal information security legislation.
  • The systems in place were insufficient to ensure that the premises were cleaned to a suitable standard.

We saw one area of outstanding practice:

  • The practice was outstanding in collaboration with outside agencies and methods used to encourage patient engagement with health promotion projects, for example, the practice had worked with a charitable trust to distribute cold weather advice and a cold weather risk reduction pack to older patients. These were distributed when patients received their flu vaccines and home visits. The pack contained information about minimising the effects of cold weather and practical items which included, a radiator key, a torch and a room thermometer. Information about how to reduce social isolation was also included. The practice had distributed 50 packs and the plan was to offer a pack to eligible patients at their appointment.

The areas where the provider must make improvements are:

  • The provider must ensure medicines are managed safely and all infection control risk assessments are completed and the appropriate mitigating action taken.

The areas where the provider should make improvements are:

  • Extend the use of clinical audits to include using the results to action changes to improve the standard of care and treatment provided.
  • Update the safeguarding policy and procedure to include information about all types of abuse and safeguarding concerns.
  • Develop systems that will assure that all policies, procedures and activities are operating as intended.
  • Ensure there is a cleaning rota for the building which is monitored.
  • Provide front of house staff with training in recognising and dealing with the early signs of sepsis.
  • Develop a register of patients in vulnerable situations.
  • Monitor the processes for obtaining consent from patients.
  • Act to assure themselves that staff who are on placement have been appropriately vetted to work with children and vulnerable adults.
  • Consider reviewing how performance data is inputted.
  • Put systems in place to ensure paper documents are always kept secure.
  • Risk assess the choice of emergency medicines provided and carried in the doctors’ bags.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.