Background to this inspection
Updated
20 October 2021
Abridge Surgery is located in the village of Abridge, Essex:
37 Ongar Road, Abridge
Romford
Essex
RM4 1UH
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury family planning and surgical procedures.
The practice is situated within the West Essex Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 4,081. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices.
Information published by Public Health England shows that deprivation within the practice population group is in the sixth lowest decile (6 of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is, 94% White, 2.5% Asian, 1.8% Mixed, 0.8% Black and 0.4% Other.
There is a partnership of two male GPs. They employ two regular locums to cover surgeries on Wednesday and Fridays and GP leave. The practice has a team of two nurses and one healthcare assistant who provide nurse led clinic’s for long-term condition. The GPs are supported at the practice by a team of reception/administration staff. The practice manager and assistant practice manager are based at the main location to provide managerial oversight.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered an appointment at the main GP location.
Extended access is provided locally by The West Essex GP extended access service, where late evening and weekend appointments are available. Out of hours services are provided by Herts Urgent Care.
Updated
20 October 2021
We carried out an announced focused comprehensive inspection at Dr. D. Colvin & Dr. O.B. Isinkaye on 09 September 2021. Overall, the practice is rated as Good.
Safe - Requires Improvement
Effective – Good
Well-led – Good
Following our previous inspection on 23 September 2019, the practice was rated Requires Improvement overall. The practice was rated Good for Safe, Caring and Responsive services and Requires Improvement for Effective and Well-led services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for on Dr. D. Colvin & Dr. O. B. Isinkaye our website at www.cqc.org.uk
Why we carried out this inspection.
This inspection was a focused inspection to follow up on:
- Safe, effective and well-led key questions.
- Breaches of regulation and areas where the provider ‘should’ improve, identified in the previous inspection.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. 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
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short site visit
- Sending a questionnaire to practice staff to complete.
- Talking to external stakeholders
Our findings
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 good overall and good for all populations groups except for people with long term conditions which was rated as requires improvement.
We found that:
- The practice had acted on issues identified at the last inspection.
- The practice had clear systems, practice and processes to keep people safe and safeguarded from abuse.
- The practice did not always demonstrate safe and effective systems. Oversight of staff immunisations and systems to manage premises/security and health and safety action plans required strengthening.
- The practice learned and made improvements when things went wrong. However, staff did not understand how to raise concerns externally, and process did not encourage a culture of candour, openness and honesty.
- The practice carried out clinical audits as part of their quality improvement activities. However, the process did not always demonstrate identify improvements.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
Whilst we found no breaches of regulation, the provider should:
- Improve processes related to checking immunisation of staff.
- Continue to review systems in place to ensure effective arrangements for identifying, managing and mitigating risks.
- Strengthen the system for recording and acting on significant events.
- Continue to improve the uptake of child immunisations and improve the monitoring of patients with long-term conditions.
- Develop audit processes so that improvements are clearly identified.
- Strengthen systems to allow staff protected time for learning and development and access to regular appraisals.
- Ensure that the recording of DNACPR decisions are consistently documented in health records.
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