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Archived: Acton Lane Surgery Good

The provider of this service changed - see new profile


Inspection carried out on 9 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Acton Lane Surgery on 9 June 2016. Overall the practice is rated as good.

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

  • Some risks to patients were assessed and well managed, with the exception of those relating to Legionella infection, gaps in fire safety awareness training and fire evacuation drills. The provider addressed these issues shortly after our inspection.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Patients said they were treated with compassion, dignity and respect and the majority of patients felt the nurses involved them in their care and decisions about their treatment.
  • The practice proactively sought feedback from staff and patients. However, action taken to improve on some areas of the service that had been rated as below local or national averages by patients were not clearly outlined.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care.
  • There was a walk-in clinic every morning and urgent appointments were 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 practice had not documented actions taken in response to patient feedback, and a risk assessment and infection control audit had not been dated to indicate when they were undertaken.
  • The provider was aware of and complied with the requirements of the duty of candour.

There are areas where the provider should make improvements:

  • Document clearly actions and processes pertaining to the running of the service are clearly documented, such as for risk assessments and infection control audits conducted, and actions taken in response to feedback from patients about the service.

  • Implement effective systems to monitor and improve the quality of the services where improvements are identified as required. Specifically, improve patient engagement and monitoring in relation to areas of high exception reporting.

  • Raise non-clinical staff awareness of the relevant consent and decision-making requirements of the Mental Capacity Act.

  • Maintain on-going training in order to protect patients from any associated risks to their health and welfare caused by insufficient training.

  • Consider displaying the mission statement so it is visible within the practice.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice