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Inspection carried out on 20 September 2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection of Avisford Medical Group on 27 February 2019. The overall rating for the practice was good. The practice was also rated good for providing safe, effective, caring and responsive services. All the population groups were rated good. It was, however, rated as requires improvement for providing well-led services. This was because: -

  • Learning from significant events and complaints was not always used or shared effectively to make improvements.

The full comprehensive report on the 27 February 2019 inspection can be found by selecting the ‘all reports’ link for Avisford Medical Group on our website at .

After the inspection in February 2019 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

This inspection was an announced focused inspection carried out on 20 September 2019 to ensure that the practice was now complying with the regulations.

Overall the practice continues to be rated as good, however it is still rated as requires improvement for providing well led services.

At this inspection our key findings were: -

  • There was some evidence to show that the practice regularly discussed significant events and complaints and shared the findings and some of the lessons learned with staff.

However, we also found: -

  • Whilst the practice had a policy for reporting significant events, it did not make clear what constituted a significant event or how they should be prioritised.
  • The practice did not maintain an accurate or complete chronological log or summary of significant events to enable it to monitor action and identify trends.
  • Records of significant events were brief and there was limited evidence to show whether enough information gathering or investigations in to the root cause had taken place.
  • Appropriate action and lessons learned were not always identified.
  • There was limited evidence to show that agreed actions had been monitored or implemented.
  • The practice did not maintain a clear audit trail or accurate log of complaints
  • Complaints records indicated that learning was not always widely shared and that a culture of openness and transparency was not embedded.
  • The practice had not implemented a system for assuring that all safety alerts received were disseminated appropriately and acted on.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

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

Inspection carried out on 27 February 2019

During a routine inspection

We previously carried out an announced comprehensive inspection at Avisford Medical Group on 20 April 2018. The overall rating for the practice was requires improvement. This was because arrangements were not in place to ensure services were provided in a safe way to patients, effective arrangements for ensuring good governance were not in place and the practice needed to ensure staff received the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties. The full comprehensive report on the 20 April 2018 inspection can be found by selecting the ‘all reports’ link for Avisford Medical Group on our website at .

After the inspection in April 2018 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

We carried out an announced comprehensive follow up inspection at Avisford Medical Group on 27 February 2019. At this inspection we followed up on breaches of regulations identified at our previous inspection on 20 April 2018.

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 in four of the key questions except for the well led domain, where the practice still requires improvement. The practice is rated as good for all population groups.

We rated the practice good for providing safe, effective caring and responsive services because:

  • Risks to patients, staff and visitors were assessed, monitored and managed in an effective manner.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.
  • Practice performance against the quality and outcomes framework indicators showed that practice performance was higher than average in several areas, for example for patients suffering with dementia.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patient survey results were positive and higher than average in some areas including patients overall experience of the practice.
  • Patients found the appointment system easy to use and reported that they could access care when they needed it.
  • There was an active patient participation group in place who told us that they had seen improvements within the practice. They told us the practice listened to patient views and acted on them.
  • Staff were positive about working in the practice and felt valued and supported in their roles. They had access to essential training and were encouraged to develop in their roles.

We rated the practice requires improvement for well led because:

  • Learning from significant events and complaints was not always used or shared effectively to make improvements.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Improve the uptake for cervical screening to ensure at least 80% coverage in line with the national target.
  • Keep a central record that provides an audit trail of action taken in response to external medicine and patient safety alerts.

Dr Rosie Bennyworth BS BMedSci MRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection carried out on 20/04/2018

During a routine inspection

This practice is rated as Requires Improvement overall. (Previous inspection August 2016 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced inspection at Avisford Medical Group on 20 April 2018. The inspection was part of our planned inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was an active patient participation group in place who told us that they had seen improvements within the practice.
  • Staff were positive about working in the practice and felt valued and supported in their roles.
  • Patient survey results were positive and higher than average in a number of areas.
  • Leaders were able to demonstrate an understanding of the key external challenges to the practice, such as recruitment of GPs and an increasing patient population and were successfully addressing them. For example they had managed to recruit additional salaried GPs and a nurse practitioner. 

However :-

  • Risks to patients were not always assessed and well managed. For example in relation to health and safety, legionella, fire, infection control and medicines management.
  • The practice was unable to demonstrate that staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. For example not all staff had received training on safeguarding children and vulnerable adults relevant to their role. Training records were not accurate or kept up to date.
  • The practice had not established proper policies, procedures and activities that were accessible to staff, to ensure safety and assure themselves that they were operating as intended. For example, on safeguarding children and vulnerable adults, infection control and medicines management.
  • Patients’ care records were not kept securely at all times where they could only be accessed, amended, or securely destroyed by authorised personnel.

The areas where the provider must make improvements are:-

  • Ensure care and treatment is provided in a safe way to patients
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider should make improvements are:

  • Provide awareness training for all staff on the ‘red flag’ sepsis symptoms that might be reported by patients and how to respond.
  • Undertake audits of clinical decision making and non-medical prescribing by staff employed in advanced roles.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection carried out on 30 August 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice


We carried out an announced comprehensive inspection at Avisford Medical Group on 30 March 2016. At this inspection the overall rating for the practice was Good. The domains of Effective, Caring, Responsive and Well Led were rated as Good. The Safe domain was rated as Requires Improvement. The full comprehensive report for the inspection undertaken on the 30 March 2016 can be found by selecting the ‘all reports’ link for Avisford Medical Group on our website at www.cqc.org.uk.

This inspection was an announced focused follow up inspection carried out on 30 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in March 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

At the inspection in March 2016 we found there were areas of practice where the provider needed to make improvements. We said the provider must:

  • Conduct regular checks to ensure equipment is safe to use and clinical equipment is working properly.

  • Carry out regular fire evacuation drills.

At the inspection in March 2016 we said the provider should:

  • Ensure the practice induction checklist is completed and held on file for all new employees.

  • Introduce a central record of recruitment checks for staff.

At our latest inspection on 30 August 2017 we found that significant improvements had been made:

  • The provider had introduced a new protocol which ensured that regular equipment checks had been made. Portable appliance testing had been carried out. All equipment including clinical equipment had been checked by nurses on a daily basis and by a professional contractor on an annual basis or more regularly if required.

  • Three fire evacuation drills had been completed in the last 12 months. The provider had introduced a system of fire evacuation drills every six months.

  • The practice had introduced a new induction procedure which ensured that appropriate training, support and checks were completed for all new members of staff and monitored by their line manager.

  • The provider had introduced a central record of recruitment checks for staff. This ensured that the necessary documents were obtained and checks were completed for all new members of staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 30 March 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Avisford Medical Group on 30 March 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 an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed. However, improvement was needed in central record keeping of staff recruitment checks and training needs and in safety of equipment.
  • 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 named 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 must make improvements are:

  • Conduct regular checks to ensure equipment is safe to use and clinical equipment is working properly.

  • Carry out regular fire evacuation drills.

The area where the provider should make improvement is:

  • Ensure the practice induction checklist is completed and held on file for all new employees.

  • Introduce a central record of recruitment checks for staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice