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Headstone Road Surgery Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 15 April 2019

We carried out an announced comprehensive inspection at Headstone Road Surgery on 12 February 2019 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, including all population groups.

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

  • The practice did not have effective systems and processes to keep patients safe. This included, fire safety and health and safety risk assessments.
  • The practice did not have appropriate systems in place for the safe management of some medicines.
  • The facilities were not always appropriate for the services being delivered. The practice could not accommodate both wheelchair users and mothers with pushchairs due to space constraints.
  • There was no disabled patient toilet and the one patient toilet was not wheelchair friendly. There were no grab rails for patients with mobility issues, or an emergency call button.
  • The practice did not have an effective system to learn and make improvements when things went wrong.

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

  • Not all staff could demonstrate the skills, knowledge and experience to carry out their roles. For example, not all staff were aware of the principles of obtaining consent in adults lacking capacity and could not undertake contraceptive reviews effectively.
  • The practice had not identified that an error relating to a childhood immunisation while registered at another practice.

These areas affected all population groups so we rated all population groups as requires improvement.

We rated the practice as requires improvement for providing well-led services because:

  • There were gaps in overall governance arrangements.
  • Facilities were not always appropriate for the service being delivered.
  • The practice did not have clear and effective processes for managing risks, issues and performance.

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

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Information leaflets were available in other languages and in easy read format.
  • Patients were able to access care and treatment in a timely way.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Clearly identify where to locate the safeguarding contacts on the safeguarding policies. 
  • Monitor that Patient Group Directions are signed by relevant staff on receipt or during new staff induction.
  • Continue to monitor and improve on patient satisfaction in relation to feeling involved in their care.  
  • Consider displaying bereavement leaflets around the practice.
  • Install a hearing loop at the practice.
  • Implement the whistle blowing policy in line with the NHS Improvement Raising Concerns (Whistleblowing) Policy.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas


Requires improvement


Requires improvement


Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement