Broken Cross Surgery

We carried out a comprehensive inspection of Broken Cross Surgery on 28 January 2019. We rated the practice Good overall but Requires Improvement for providing safe services because there were breaches of regulations. The breaches were:

• Regulation 12 Safe Care and Treatment, as some patient group directives (PGDs) for the authorisation of vaccines had not been appropriately signed;
• Regulation 13 Safeguarding, as some clinicians had not received up to date safeguarding training appropriate to their role.

We also recommended that the practice should:

• Review key policies to keep up to date with best practice.
• Update the recruitment process to incorporate an overview of an applicant’s health.
• Review how the lead for infection control keeps up to date with best practice for infection control and prevention.
• Carry out regular fire drills.

At this inspection 13 January 2020, we found that the provider had satisfactorily addressed these areas and therefore the practice is now rated as good for providing safe services.

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.

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

At the previous inspection on 4 December 2014 the practice was rated as outstanding for providing responsive and well led services and an overall rating of outstanding. Having now inspected all GP practices we have a better understanding of the baseline so what we assessed as being outstanding previously, now would not be rated as outstanding. This is because initiatives that were previously regarded as innovative or unusual may no longer be so because things have moved on in primary care

We carried out an announced comprehensive inspection at Broken Cross Surgery on 28 January 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 good overall and good for all population groups.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• There was a system in place for investigating and responding to patient feedback including complaints.

• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• There was a focus on continuous learning and improvement at all levels of the organisation.

We saw areas of outstanding practice including:

• We saw evidence of the practice providing support to vulnerable patients to build trust to encourage them to access the practice. The practice ensured that patients with a learning disability were supported by a named nurse to build trust, relationships and understanding of communication needs and methods.

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

• The majority of clinical staff did not have safeguarding training appropriate to their roles and responsibilities.
• Two Patient Group Directions (PGD) were examined and we found they had not been appropriately dated, signed and authorised. We noted that a staff members name had been added after the date it had been authorised by a GP

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Ensure that clinical staff have received safeguarding training at a suitable level to their role.

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

The areas where the provider should make improvements are:

• Review key policies and procedures at regular intervals to ensure they are in line with current legal requirements and best practice.
• Ensure that suitable infection control training or peer support is provided to the designated infection control lead.
• Ensure that the practice’s recruitment process considers an applicant’s physical and mental health in line with the requirements of the role.
• Ensure that fire drills take place at regular intervals.

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