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Inspection carried out on 17 Jan 2019

During a routine inspection

Inspection carried out on 11/01/2018

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Abbey Road Surgery on 27 September 2016. Overall the rating for the practice was inadequate; specifically it was rated inadequate for providing safe and well-led services, requires improvement for providing caring and responsive services and good for providing an effective service. As a result, the practice was placed into special measures for a period of six months.

We carried out an announced comprehensive inspection at Abbey Road Surgery on 25 May 2017. Overall the rating for the practice was requires improvement; specifically it was rated as inadequate for safe services, requires improvement for responsive and well-led services and good for providing an effective and caring service. The practice remained in special measures for a period of six months.

The full comprehensive reports on the September 2016 and May 2017 inspections can be found by selecting the ‘all reports’ link for Abbey Road Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 11 January 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 25 May 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

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 had systems to safeguard children and vulnerable adults from the risk of abuse. Staff demonstrated that they understood their responsibilities.
  • 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.
  • Staff worked with other health and social care professionals to deliver effective care and treatment.
  • Staff treated patients with compassion, kindness, dignity and respect.
  • Patients 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.
  • Governance structures, systems and processes were effective and enabled the provider to identify, assess and mitigate risks to patients, staff and others.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Continue to review the national GP patient survey results and ensure steps are taken to make improvements where required.
  • Continue to encourage patient attendance at cancer screening programmes.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 25/05/2017

During a routine inspection

We carried out an announced comprehensive inspection at Abbey Road Surgery on 27 September 2016. Overall the rating for the practice was inadequate; specifically it was inadequate for safe and well-led, requires improvement for caring and responsive and good for effective, and was placed in special measures for a period of six months.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 25 May 2017; overall the practice is rated as requires improvement.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly embedded systems and processes which promoted learning from events and clear communication with all staff members.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety. The practice had a clear system in place for the effective management of national safety alerts. However at the time of inspection, the practice did not have an effective system in place to ensure patients received the required checks before being prescribed certain medicines which required monitoring.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Patient comments highlighted that they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients we spoke with 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. However, the most recent National GP Patient Survey results showed the practice was performing below local and national averages.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Staff felt supported by management and the practice proactively sought feedback from staff and patients, which it acted on.
  • Not all governance structures, systems and processes were effective and enabled the provider to identify, assess and mitigate risks to patients, staff and others.
  • The provider was aware of the requirements of the duty of candour. The examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvements are:

  • Ensure systems and processes are in place for the safe prescribing of medicines which require monitoring.

The areas where the provider should make improvements are:

  • Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
  • Review the patient recall process to ensure the system is effective and comprehensive.
  • Develop a system to identify vulnerable adults on the computer system.
  • Continue to review the National GP Patient Survey results and ensure steps are taken to make improvements where required.
  • Continue to encourage patient attendance at cancer screening programmes.
  • Implement a process to ensure uncollected prescriptions are appropriately managed.

This service was placed in special measures on 27 September 2016. Improvements have been made and conditions imposed on the service will now be removed. However, there remains a rating of inadequate for providing safe services. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 27/09/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Abbey Road Surgery on 27 September 2016. This was to check that improvements had been made following the breaches of legal requirements we identified from our comprehensive inspection carried out on 29 July 2015. Overall the practice is rated as inadequate.

Our previous inspection in July 2015 found breaches of regulations relating to the safe, effective, responsive and well-led domains. The overall rating of the practice in July 2015 was requires improvement.

The areas identified as requiring improvement during our inspection in July 2015 were as follows:

  • Ensure recruitment arrangements include all necessary employment checks for all staff. This includes making sure all nursing staff have a criminal records check through the Disclosure and Barring Service (DBS). Where non-clinical staff perform chaperone duties, the practice must risk assess whether a DBS check is required.
  • Complete the actions identified in the infection control audit and review systems in particular relating to hand washing and the use of disposable towels. Carry out a risk assessment for the management, testing and investigation of legionella and implement any recommended checks to the water system. Use the correct disposal bins for sharps used for the administration of cytotoxic medications.
  • Have essential equipment such as oxygen available for use in an emergency.
  • Develop a system for the management of high risk medications that includes regular review and monitoring of the patient.
  • Continue to review the telephone and appointments system in response to patients’ concerns about access to the practice.

Following our inspection on 27 September 2016, our key findings across all the areas we inspected were as follows:

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, the practice did not have effective systems in place for the effective management of national safety alerts.

  • We found an inconsistent approach towards the management of significant events and complaints. There was no evidence of learning and communication with all relevant staff.
  • The practice had regularly monitored the Quality and Outcomes Framework and had made significant improvements to their performance across several areas
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

  • Not all governance structures, systems and processes were effective and enabled the provider to identify, assess and mitigate risks to patients, staff and others.
  • Patient comments highlighted that they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. However, the practice performed below average for most areas in the National GP Patient Survey. The practice did not offer extended opening hours.
  • The practice did not have a clear leadership structure. Staff members were unable to describe the vision and values of the practice and not all staff members felt supported by management.

The areas where the provider must make improvements are:

  • Systems and processes must be established and operated effectively to ensure good governance and leadership.

  • Ensure systems and processes for the management of patient safety alerts, significant events and complaints are effective, including actions taken and sharing of learning with relevant staff.
  • Ensure that systems designed to assess the risk of and to prevent, detect and control the spread of infection are fully implemented and monitored in all relevant areas. Including infection control training for all staff members and the management of clinical waste in accordance with national guidelines.
  • Complete an assessment on the control of substances hazardous to health.
  • Ensure formal supervision of the nurse prescriber in line with the practice clinical supervision policy.
  • Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.

The areas where the provider should make improvements are:

  • Ensure electrical equipment is checked on a regular basis to ensure it is safe to use.
  • Ensure steps are taken to make improvements to the National GP Patient Survey results; including access to routine pre-bookable appointments and access to the practice by telephone.
  • Review and make improvements to the baby changing area and disabled patient toilet facilities provided in line with the requirements of the Equality Act 2010.
  • Ensure all policies are reviewed and are up-to-date.
  • Develop a practice business plan to include the practice vision, aims and objectives, with the involvement of all staff members.
  • Ensure an appropriate system is in place for the safe monitoring of blank prescriptions
  • Consider developing a quality improvement plan to ensure continuous improvement

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 29 July 2015

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Abbey Road Surgery on 29 July 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe, effective, responsive and well led services. It also required improvement for providing services for older people, people with long-term conditions, people whose circumstances make them vulnerable, families, children and young people, working people and those who have recently retired and people experiencing poor mental health. It was good for providing a caring service.

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

  • Staff understood their responsibilities to raise concerns, and to report incidents and near misses.
  • Systems were in place to identify and respond to concerns about the safeguarding of adults and children.
  • Data showed patient outcomes were below average for the local area.
  • We saw staff were respectful and friendly when communicating with patients.
  • Urgent appointments were usually available on the day they were requested. However, patients said that they sometimes had to wait a long time to get through to the practice by telephone.
  • The practice was developing a patient participation group (PPG) to gather feedback from patients to help improve services.
  • Adequate recruitment procedures including completing the required background checks on staff were lacking.
  • Staff did not always receive the appropriate supervision, appraisal and essential training to complete their roles effectively.

The areas where the provider must make improvements are:

  • Ensure recruitment arrangements include all necessary employment checks for all staff. This includes making sure all nursing staff have a criminal records check through the Disclosure and Barring Service (DBS). Where non-clinical staff perform chaperone duties, the practice must risk assess whether a DBS check is required.
  • Complete the actions identified in the infection control audit and review systems in particular relating to hand washing and the use of disposable towels. Carry out a risk assessment for the management, testing and investigation of legionella and implement any recommended checks to the water system. Use the correct disposal bins for sharps used for the administration of cytotoxic medications.
  • Have essential equipment such as oxygen available for use in an emergency.
  • Develop a system for the management of high risk medications that includes regular review and monitoring of the patient.
  • Continue to review the telephone and appointments system in response to patients’ concerns about access to the practice.

In addition the provider should:

  • Follow the protocol for reporting, recording and monitoring significant events, incidents and accidents so learning is identified and shared with practice staff.

  • Ensure a system is in place for all staff to remain up to date with essential training such as safeguarding vulnerable adults, fire safety and equality and diversity.
  • Ensure that all nursing staff employed are supported by receiving appropriate supervision and appraisal and complete the training relevant to their roles.
  • Consider including the nursing staff in the clinical meetings to discuss any clinical matters, updates or concerns.
  • Follow the correct process for the storage of liquid nitrogen.
  • Keep the original logs of room and fridge temperature checks for audit purposes.
  • Make use of care plans to take into consideration patients’ wishes for those with long term conditions or complex needs.
  • Review quality data periodically to ensure monitoring of care and outcomes for patients.
  • Keep a copy of the business continuity plan off site so this can be accessed in the event of an emergency for appropriate actions to take place.
  • Ensure policies and procedures in place are relevant to the practice and all staff have an awareness of them to support their roles.
  • Follow the practice complaints procedures to ensure all complaints are investigated and responded to in an appropriate and timely manner.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice