The Care Quality Commission
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Archived: Herbert Avenue

Overall: Good read more about inspection ratings

Herbert Avenue Surgery, Lowercroft, Poole, Dorset, BH12 4HY (01202) 743333

Provided and run by:
Herbert Avenue

All Inspections

25 April 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Herbert Avenue on 14 July 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Herbert Avenue on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 25 April 2017. Overall the practice is now rated as good.

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

  • There was a new approach to the running of the practice with an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

  • Risks to the safe care of patients were more clearly managed, with the exception of legionella.

  • Staff assessed patients who attended the practice had their needs and delivered care in line with current evidence based guidance.

  • Staff had received updated training and had the skills, knowledge and experience to deliver effective care and treatment.

  • Patient feedback was consistently positive about the standard of care received.

  • Information about services and how to complain was available and easy to understand.

  • Complaints were investigated appropriately and in a timely manner.

  • 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 proactively sought feedback from staff and patients, which it acted on.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • The provider was aware of and complied with the requirements of the Duty of Candour.

However, there remain areas where the provider must make improvement. The practice must:

  • Ensure effective governance systems are in place to oversee systems and processes within the practice. For example regarding the cleaning of clinical equipment and testing to minimise the risks of legionella.

In addition the provider should:

  • Review processes for recording consent for minor surgery, so this is consistently documented in patient notes.

  • Continue to review the process for monitoring patient outcomes so that exception reporting becomes in line with local and national averages.

  • Review the provision of support for patients with English as an additional language.

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

22 November 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out a focussed inspection of Herbert Avenue Surgery on 22 November 2016 to review actions taken by the practice in regard of the Warning notice. This review was performed to check on the progress of specific actions taken following the inspection we made in July 2016 and does not affect the current rating for the practice. We requested an action plan following the inspection in July 2016 which detailed the steps the practice would take to meet their breaches of regulation, these included;

  • Systems or processes in regard of governance; and,

  • Systems or processes in regard of risks to patients.

We found improvements had been made since the previous inspection of July 2016 when the practice had been rated as inadequate and was placed into Special Measures. The requirements from the Warning Notice we served have been met; we will carry out a further inspection of the practice to ensure other requirements have been met in the near future; therefore the ratings remain the same as our last report.

This report covers our findings in relation to the requirements and should be read in conjunction with the report published on 3 November 2016. This can be done by selecting the 'all reports' link for Herbert Avenue on our website at www.cqc.org.uk

Our key findings at this inspection were as follows:

  • The practice had put in place governance arrangements for new policies and procedures to make improvements following the last inspection; some of the new arrangements were at an early stage and had not been fully embedded into the practice.

  • Staff understood the systems and processes and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.

  • There was a clear leadership structure and staff felt supported by management. The staff were keen to show the progress made and we saw they had made improvements and been very engaged with the process.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

14 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Herbert Avenue on Thursday 14 July 2016. Overall the practice is rated as inadequate

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

Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not thorough or shared routinely with all staff to ensure patient safety or to improve the services provided. Patients did not always receive a timely apology.

Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, actions identified to address concerns with fire safety, health and safety and infection control practice had not been taken.

Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence the practice was comparing its performance to others; either locally or nationally.

Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements to ensure patient safety or to improve the services provided.

The areas where the provider must make improvement are:

  • Ensure actions are taken to address identified concerns with infection prevention, fire prevention and health and safety control practice.

  • Ensure systems are in place to ensure all GPs and nurses are kept up to date with national guidance, updates and guidelines including national patient safety alerts

  • Ensure formal governance arrangements are implemented including systems for assessing and monitoring risks and the quality of the service provision including a systemic programme of clinical audits to ensure improvements in patient outcomes have been achieved.

  • Ensure systems are put in place to ensure the security and monitoring of prescription forms.

  • Ensure systems and processes are put in place to improve communication between all staff teams; particularly in regard of sharing learning from incidents, complaints, audits and service feedback.

The areas where the provider should make improvement are:

  • Ensure systems and processes are established and operated effectively to prevent the possible abuse of service users, including providing up to date safeguarding and Mental Capacity Act 2005 training for all staff.

I am placing this service in special measures. Where a service is rated as inadequate for one of the five key questions or one of the six population groups or overall and after re-inspection has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we place it into special measures.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as 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 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.

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