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Review carried out on 21 November 2019

During an annual regulatory review

We reviewed the information available to us about Audley Health Centre on 21 November 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 27 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Audley Health Centre (also known as Stepping Stone Practice) on 27 October 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • Risks to patients were assessed and generally well managed. We noted there were opportunities for the improvement of coordination and management of risk management activity with other building occupants.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a GP and there was continuity of care, with urgent appointments available the same day.
  • 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.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Review and improve the management and segregation of significant event and complaint records.
  • Consider the development of systems and processes to gain assurance that all building related risks are identified and mitigated.
  • Clarify and record responsibilities for shared areas of the practice building. Consider the development of systems and processes to gain assurance that appropriate checks of shared equipment in these areas are completed to ensure the equipment remains fit for use.
  • Consider the development and implementation of systems and processes to ensure clinical audit activity is fully completed and effective.
  • Review and improve practice policy review activity.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice