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Apsley Surgery Requires improvement

We are carrying out a review of quality at Apsley Surgery. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 12 March 2020

We previously carried out an announced, comprehensive of Apsley Surgery on 20 August 2015 and rated the practice as good overall and in all five key questions.

The full comprehensive report for the inspection in August 2015 can be found by selecting the ‘all reports’ link for Apsley Surgery on our website at www.cqc.org.uk.

We carried out an announced, comprehensive inspection at Apsley on 4 February 2020 as part of our inspection programme.

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 in effective and well-led, inadequate in safe and good in effective and caring. We rated each population group as good except for families, children and young people and working age people which we rated as requires improvement.

We rated the practice as inadequate in safe because:

  • There were gaps in staff training. For example, safeguarding, fire safety and fire marshal.
  • All the required risk assessments had not been completed to mitigate potential risks.
  • Alerts had not been added to the records of the parents of a child with a child protection plan in place. The practice was unable to hold regular meetings with health and social care professionals, to protect vulnerable adults and children at risk of harm due to circumstances outside of their control.
  • All the required recruitment documents were not available for all members of staff employed by the practice. DBS checks or risk assessments to mitigate potential risks had not been completed for non-clinical staff particularly those who chaperoned.
  • A formal system of clinical review of the prescribing competence of three non-medical prescribers was not in place. However, following our inspection the practice forwarded to us evidence of how this would be completed.
  • Opportunities to raise significant events had been missed. A system for recording and reviewing significant events over time to identify trends was not in place.
  • Not all staff had received the immunisations appropriate to their role. Used sharp’s boxes had not been collected within three months after first use, even if not full.
  • Sharp’s boxes were not available at the branch practice.
  • The in-house fire risk assessment completed for the branch practice had failed to identify two risks.
  • Fire drills had not been carried out at the branch practice.
  • The legionella risk assessment for the branch practice showed there were 12 areas that need to be addressed. However, there was no evidence to demonstrate that 11 of these areas had been completed.
  • The system for tracking prescription stationery throughout the branch practice was not effective.
  • The practice did not hold all the suggested emergency medicines at the main or branch practice. Risk assessments for all the missing medicines had not been completed.
  • Oxygen, airway management equipment for children and a defibrillator were not available at the branch site. A risk assessment to mitigate potential risks to patients had not been completed.

We rated the practice as requires improvement in effective because:

  • The practice had not met the minimum 90% target for all four childhood immunisation uptake indicators. The uptake of the immunisation for haemophilus influenza type b and meningitis C booster was significantly below target.
  • Screening rates for breast cancer and bowel cancer were below local and national averages.
  • Cervical screening rates were significantly below the national target.

We rated the practice as good in caring because:

  • Staff treated patients with kindness, respect and compassion.
  • The practice respected patients’ privacy and dignity.

We rated the practice as good in responsive because:

  • The practice organised and delivered services to meet patients’ needs.
  • People were able to access care and treatment in a timely way.

We rated the practice as requires improvement in well-led because:

  • Systems for identifying, managing and mitigate risks were ineffective.
  • Governance meetings including clinicians had not been established.
  • An overarching system to review trends in significant events and complaints over time was not in place.
  • Staff did not know or understand the practice’s vision, values and strategy.

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.
  • Ensure specified information is available regarding each person employed.

The areas where the provider should make improvements are:

  • Explore and implement strategies to increase the uptake of childhood immunisations, breast and bowel cancer screening.
  • Review the effectiveness of strategies implemented to increase the uptake of cervical screening.
  • Establish in-house safeguarding meetings to protect vulnerable adults and children.
  • Ensure information regarding how to complain is readily available for patients to access within the practice.
  • Support staff to understand the practice’s vision, values and strategy.

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

Inspection areas

Effective

Requires improvement

Well-led

Requires improvement
Checks on specific services

People with long term conditions

Good

Families, children and young people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good