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Inspection carried out on 24 October 2017

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Station Road Surgery on 14 June 2017. The overall rating for the practice was Good. However we rated the practice as Requires Improvement for providing safe services. The full comprehensive inspection report can be found by selecting the ‘all reports’ link for Station Road Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 24 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation which we identified at our previous inspection on 14 June 2017. The report covers our findings in relation to that requirement and also additional improvements made since our last inspection.

The practice is now rated as Good for providing safe services.

Our key findings were follows:

  • Processes for receiving and acting upon patient safety alerts had been improved. Systems had been streamlined. Searches were made in patient records to identify patients affected by any such alerts, and appropriate action was taken when necessary.
  • Vaccine stock levels were logged and monitored.
  • Communication with locums had been improved to encourage attendance at meetings, or disseminating of minutes from meetings where attendance was not possible.
  • The practice was continuing to engage with patients to review satisfaction with access to appointments. The practice was participating in a CCG wide audit of patient satisfaction with access to appointments with GPs, which was due to end on 6 November 2017.

However we found one area where the provider should make an improvement:

The provider should:

  • Deliver on their plan to carry out any remaining staff appraisals by December 2017.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 14 June 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Station Road Surgery on 14 June 2017. Overall the practice is rated as good. We rated the practice as requires improvement for providing safe services to the population it serves.

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

  • The practice had undergone a period of significant disruption and staffing changes in the preceding 18 months. During our inspection staff spoke positively about support they received from the GP partners and newly appointed locum practice manager.
  • The practice demonstrated an open and transparent approach to safety. Significant events were reported and recorded. At the time of our visit we saw that systems had recently been changed, and a streamlined, single process for reporting and recording internal significant events had been implemented.
  • There were systems in place to monitor risks to patient safety. At the time of our inspection we saw there were gaps in logs kept of vaccine refrigerator monitoring. Following our inspection these logs were found, and samples forwarded as evidence of continuous monitoring.
  • We saw that Medicines and Healthcare Products Regulatory Agency (MHRA) alerts were not always acted upon in a timely way. 
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • We saw that an induction programme was in place for staff.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had responded to patient feedback in relation to appointment access, and telephone systems. The telephone system had recently been changed to improve patient experience. Appointment availability was closely monitored, and a range of appointment options were available, including telephone triage, urgent and routine appointments.
  • The practice had some limitations in relation to premises. However we saw that good use had been made of the space available. Premises were accessible to patients with limited mobility, or those who used a wheelchair.

  • There had been recent disruption to the leadership structure in the practice. Staff told us they felt able to make suggestions and give feedback, and action was taken in response to this when appropriate.
  • The practice had a long established patient participation group. The practice worked closely with them to respond to patient feedback and initiate change or improvement in response to this.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

We saw one area of outstanding practice:

  • The practice had held a men’s health open day. The event attracted 45 attendees between the ages of 40 and 60. Of these, 35 attendees (78%) were identified as requiring further investigation and follow up for unmet health needs, such as pre-diabetes and hypertension. Each of these patients were directed to the appropriate follow up and treatment by the practice. Evaluations completed by attendees showed that 100% of respondents would recommend the service; and said that they felt better informed about their health as a result of the event. The practice told us they had plans to repeat these events in future.

The area where the provider must make improvement is:

The provider must do all that is reasonably practicable to assess, monitor, manage and mitigate risks to the health and safety of patients who use the service. Specifically, medicines and other patient safety alerts must be responded to in a timely manner.

In addition the provider should:

  • Maintain systems to log and monitor vaccine stock levels

  • Continue to improve communication systems for temporary locum staff.

  • Continue to engage with patients to review satisfaction with access to appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 10 November 2015

During a routine inspection

Letter from the Chief Inspector

We carried out an announced comprehensive inspection at Station Road Surgery on 10 November 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 incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed

  • Risks to patients were assessed and managed. We identified some areas with regard to infection prevention and control and medicines management during our inspection which the practice were able to rectify immediately.

  • Patients’ needs were assessed and care was planned and delivered following best practice guidelines.Staff had received training appropriate to their roles. Further training needs had been identified and planned although formal appraisals had not been carried out in all cases and training records did not identify all the training staff had completed. Appraisal dates for all staff were set for later in the year and the practice undertook to update staff training records.

  • 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

  • Patients said care provided by GPs and nurses was good although it was not always possible to see a GP of their choice. Urgent appointments were available on the same day

  • There was a clear leadership structure and staff felt supported by management. The practice acted on feedback from staff and patients. However there was no system of analysis of significant events to identify trends over time.

We saw the following areas of outstanding practice:

  • The practice had utilised innovation funds to set up a ‘Singing Group’ to help alleviate symptoms of anxiety and reduce social isolation. Patient evaluation indicated noteable improvements in perception of quality of life after attending the group

  • The partners offered an annual health and fitness session providing an open door to patients where health promotion and fitness information was discussed

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

The provider should:

  • Review the recruitment policy to ensure it is always followed when recruiting staff

  • Carry out annual appraisals for all staff

  • Develop a system of regular analysis of significant events to enable patterns and trends to be identified over time.

Professor Steve Field

CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

CQC Insight

These reports bring together existing national data from a range of indicators that allow us to identify and monitor changes in the quality of care outside of our inspections. The data within the reports do not constitute a judgement on performance, but inform our inspection teams. Our judgements on quality and safety continue to come only after inspection and we will not make judgements on data alone. The evidence tables published alongside our inspection reports from April 2018 onwards replace the information contained in these files.