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Inspection carried out on 27 June 2019

During an inspection looking at part of the service

We carried out a focused inspection at Charles Road Surgery on 27 June 2019 as part of our inspection programme.

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:

  • Are services at this location effective?
  • Are services at this location responsive?
  • Are services at this location well-led?

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 population groups.

We found that:

  • Patients received effective care and treatment that met their needs.
  • Patient outcome data (QOF) and prescribing performance was in line with CCG and national averages.
  • Staff had appropriate skills and experience to meet patient needs.
  • The practice organised and delivered services to meet patients’ needs.
  • Patients could access care and treatment in a timely way.
  • Complaints were managed appropriately and in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Risks were generally well managed. Although we identified areas where these could be improved for example in relation to infection control and completion of audit cycles.

We have rated this practice as requires improvement for the working age population group.

We found that:

  • The practice uptake of cervical cancer screening and bowel cancer screening was below local and national averages. The practice staff were aware of the cultural sensitivities and expectations in relation to health care however, no clear plans of action had been implemented as to how this might be improved.

Whilst we found no breaches of regulations, the provider should:

  • Review cervical screening and child immunisation data and identify how this may be improved.
  • Review service improvement activity to ensure improvements are sustained through completed audit cycles.
  • Revisit infection control audit to identify areas for improvement and take action as appropriate.
  • Consider on an individual basis the provision of a formal written care plan to be provided to relevant patients.

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 carried out on 2 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Charles Road Surgery on 2 July 2015. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report and record incidents and near misses. Staff used significant events and national and local safety alerts to improve the service.
  • The practice assessed risks to patients and managed these well.
  • The GPs and practice nurses assessed patients’ needs and planned and delivered care following best practice guidance.

  • Staff received training appropriate to their roles and the practice identified and planned future training and development needs.

  • Patients told us they were involved in their care and decisions about their treatment. They were positive about the practice which they described as helpful, competent, polite, respectful and re-assuring. There were differences between the very positive information we obtained and the less positive results of the national GP patient survey.
  • Information about services and how to complain was available and easy to understand but responses to complaints were not always fully documented to support shared learning.
  • 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 worked closely with its patient participation group and acted on feedback from them and other sources.

  • The practice was developing more comprehensive governance systems to support the clinicians and ensure the practice was managed effectively.

We saw some areas of outstanding practice including:

  • The practice worked with the chair of the PPG to facilitate the funeral and burial needs of Muslim patients, including when this was out of hours and the practice was closed. Community leaders and patients and their families had the contact details for the chair of the PPG. When a patient died the PPG chair contacted the practice so that death certificates could be arranged without delay and burials could take place.

  • The practice was alert to the potential risks of female genital mutilation (FGM) and forced marriage. They provided patients with information and access to specialist support. They were sensitive to the importance of taking great care to protect patients who asked for help or who they believed might be at risk.

However there were areas where the provider needs to make improvements.

Importantly the provider should:

  • Review whether the practice is due for its five yearly electrical installation checks to be carried out.

  • Take the results of patient feedback, including the national GP patient survey into account when planning improvements at the service.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 19 May 2014

During an inspection in response to concerns

In order to target our inspections effectively we continually gather information about services. This may include information from health professionals and other staff; people who use services and family members. We had received information which led us to review circumcision procedures at a number of GP practices. In order to do this CQC inspectors were accompanied by a specialist advisor in urology.

The visit to the practice was unannounced; this meant that the provider and staff at the practice did not know we were coming.

One of the GPs at Charles Road Surgery was undertaking non � medical circumcisions on male babies. Male circumcisions that are performed where there is no health need are termed non - medical circumcisions. They are generally completed for cultural reasons.

We spoke with the parents of four babies who had recently had a circumcision at the practice. They told us they were given clear details of the procedure and the associated risks. Infants were pre assessed prior to the surgery and a medical history taken. We saw, and parents told us information was given in relation to potential complications and post-operative care. However there was no system in place to ensure that, where appropriate, both parents had given consent for the procedure.

Systems were in place to monitor the quality of the services provided at the practice. The absence of regular and up to date circumcision audits meant that opportunities to monitor and improve the quality of that particular service at Charles Road Surgery had not been utilised.