The Fryent Way Surgery

We carried out an announced comprehensive inspection at Fryent Way Surgery on 1 August 2019. We previously inspected this practice on 28 June 2018. At that inspection we rated the practice as requires improvement overall as we found breaches of Regulations 12, 17 and 19 of the Health and Social Care Act. This inspection on 1 August 2019 was carried out to check if sufficient improvement had been made since the previous inspection and to confirm whether the provider was now meeting the regulations.

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.

We have rated this practice as requires improvement overall and good for all population groups.

We found that:

• The practice’s safety systems and procedures were not all planned in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed did not always promote the delivery of high-quality, person-centre care.

We rated the practice as requires improvement for providing safe services because:

• Fire safety, infection control and health and safety arrangements and processes were not effectively managed to ensure patient safety.

We rated this practice as requires improvement for being well-led because:

• There were deficiencies in the overall governance systems and risk management, for example in relation to fire safety, infection control and health and safety.

We rated the practice as good for providing effective, caring and responsive services because:

• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Review and improve the advertising of and engagement with the patient participation group to support patient involvement and feedback about the running of the practice.
• Review and improve staff engagement procedures to ensure discussions about complaints and learning from complaints is shared and documented.

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