14 November 2023
During a routine inspection
We carried out an announced comprehensive inspection at Old Station Surgery on 14 November 2023. Overall, the practice is rated as requires improvement
Safe - requires improvement
Effective - requires improvement
Caring - good
Responsive - requires improvement
Well-led - requires improvement
At our previous comprehensive inspection on 6 October 2015, the practice was rated good overall and for the key questions of effective, caring, responsive and well-led. It was rated as requires improvement for providing safe services due to an absence of Legionella risk assessments for their 3 sites. A follow-up desk top review was undertaken on 15 July 2016 which found the provider to be compliant with regulations having completed the required risk assessments, so the practice was then also rated as good for safe.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Old Station Surgery on our website at www.cqc.org.uk
Why we carried out this inspection.
We carried out this inspection due to our current inspection priorities. In this case, the practice was selected for inspection due to the length of time since our previous inspection.
How we carried out the inspection.
- An announced site visit.
- Conducting staff interviews using video conferencing prior to the site visit.
- Completing remote clinical searches on the practice’s patient records system and discussing findings with the provider (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider to be submitted electronically, and to review further evidence on site on the day of the inspection.
- Speaking with a member of the Patient Participation Group.
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 found that:
- Patients received effective care and treatment that met their needs.
- The service was not always provided in a way to respond to patients’ needs, for example in terms of the ease making an appointment. However, we saw that the practice was participating in a comprehensive improvement programme which included improving patient experience with regards to access.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice did not always have effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- The practice did not always have effective processes for identifying, managing and responding to risks.
- There was limited evidence to demonstrate that clinical audit was driving improvement in patient outcomes.
- Some staff appraisals were overdue, and there were gaps in the completion of the practice’s mandatory training programme.
We found 1 breach of our regulations. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
In addition, the provide should:
- Continue to work on processes to enhance patient experience in terms of the ease of contacting the practice to make an appointment.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care