Archived: Queens Road Surgery

Updated 7 January 2019

Updated 7 January 2019

We carried out an announced comprehensive inspection at Queens Road Surgery on 5 December 2018. This inspection was a follow up to a previous inspection on 25 April 2018, when the practice received a rating of requires improvement overall. At that time the practice was rated as good for providing effective, caring and responsive services; whilst they received a rating of requires improvement for providing safe and well led services. A breach of regulations was identified at that time. This inspection was carried out to review the changes and improvements the practice had implemented since their previous inspection, and to follow up on the breach of regulation identified at that time. Our inspection team was led by a CQC lead inspector, and included a GP specialist advisor.

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from ongoing monitoring of data about services as well as information from the provider, patients, the public and other organisations.

We have rated this practice as good overall, with the key question of are services responsive and all of the population groups rated as requires improvement.

We concluded that:

• The practice had reviewed their arrangements in relation to health and safety in the practice. A fire risk assessment had been completed and actions implemented. Fire drills were carried out in line with legal requirements and a legionella risk assessment had been completed, with identified actions implemented.
• Infection prevention and control arrangements had been revised and improved. Vaccine fridge monitoring processes were thorough, and childhood immunisation arrangements were appropriate.
• The practice had clarified their processes in relation to bullying and harassment and whistleblowing to enable staff to feel supported in raising concerns. Clear, confidential lines of reporting issues of concern had been developed and communicated to all staff.
• Practice systems for incident reporting were in place. We saw that lessons were learned and communicated to all staff.
• Care and treatment was delivered in line with up to date relevant evidence based guidance.
• Staff immunisation status had been reviewed, and arrangements put in place to ensure all staff were appropriately immunised.
• Systems for reviewing uncollected prescriptions were in place to optimise patient safety.

However, we also found that:

• There were challenges in relation to nurse recruitment. In addition, a number of key staff had recently indicated their intention to leave the practice.
• Patient feedback indicated that satisfaction with telephone access to the practice, and the experience of making an appointment was below local and national averages.

The areas where the provider should make improvements are:

• Continue to review and improve patient experience of telephone access and access to appointments.
• Continue to ensure arrangements are in place to provide appropriate cover for key staff pending permanent replacements being in post.
• Review and improve the arrangements in place for patients to be able to access a female GP if they wish to do so.

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

Updated 7 January 2019

Updated 7 January 2019

Updated 7 January 2019

Updated 7 January 2019

Updated 7 January 2019

Updated 7 January 2019