Archived: Rowe Avenue Surgery

Updated 17 January 2017

Letter from the Chief Inspector of General Practice

The practice was rated good overall and is now rated good for providing safe services.

We carried out an announced comprehensive inspection of this practice on 28 April 2016. A breach of legal requirements was found during that inspection within the safe domain. After the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the legal requirements. We conducted a focused inspection on 8 December 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.

During our previous inspection on 28 April 2016 we found the following areas where the practice must improve:

• Take action to address identified concerns with infection control.
• Ensure up to date risk assessments are undertaken in relation to fire and the safety of the premises.
• Ensure all necessary recruitment checks are undertaken for all staff.

Our previous report also highlighted the following areas where the practice should improve:

• Ensure that there is a clear audit trail in relation to the management of, and response to complaints.
• Ensure that significant event recording forms include details of where and when the event was discussed and shared with staff.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

During the inspection on 8 December 2016 we found:

• The practice had implemented cleaning schedules for all areas and that weekly checks of the environment and cleanliness were undertaken.
• An up to date fire risk assessment had been undertaken and remedial action had been taken where identified.
• Appropriate recruitment checks had been undertaken for all staff.

We also found in relation to the areas where the practice should improve:

• The practice had put in place a cover sheet for each complaint which enabled a clear audit trail in relation to receipt and responses to be recorded.
• Details of where and when significant events were shared and discussed with staff were now clearly recorded in the significant event form.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 17 January 2017

The practice was rated as good for the care of people with long-term conditions on 28 April 2016. This rating remains unchanged

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
• 90% of patients on the diabetes register, with a record of a foot examination and risk classification within the preceding 12 months (04/2014 to 03/2015) compared to the CCG average of 87% and the national average of 88%.
• Longer appointments and home visits were available when needed.
• All these patients had a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the practice worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 17 January 2017

The practice was rated as good for the care of families, children and young people on 28 April 2016. This rating remains unchanged

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.
• 77% of women aged 25-64 whose notes record that a cervical screening test has been performed in the preceding 5 years (04/2014 to 03/2015) compared to the CCG average of 83% and the national average of 82%
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• The practice worked closely with midwives, health visitors and school nurses.

Updated 17 January 2017

The practice was rated as good for the care of older people on 28 April 2016 . This rating remains unchanged

• The practice offered proactive, personalised care to meet the needs of the older people in its population.
• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
• Patients from the practice were able to access free community transport to local health service sites including acute and community hospitals and health centres.
• The practice worked with multidisciplinary teams to ensure those with complex health and social care needs had a care plan in place in order to prevent unnecessary, unplanned admission to hospital.
• The practice was able to refer older people to a community hospital based consultant geriatrician who enabled them to be seen closer to home and potentially avoid hospital admission

Updated 17 January 2017

The practice was rated as good for the care of working age people (including those recently retired and students) 28 April 2016. This rating remains unchanged

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

Updated 17 January 2017

The practice was rated as good for the care of people experiencing poor mental health (including people with dementia) on 28 April 2016. This rating remains unchanged

• As a result of an audit the practice had implemented a number of improvements to ensure its premises met the needs of people with dementia. This included artwork, signage and a clock designed especially to meet the needs of people with dementia.
• 70% of patients diagnosed with dementia that had their care reviewed in a face to face meeting in the last 12 months, compared to the CCG average of 82% and the national average 84%.
• The practice made regular referrals to a local dementia café that provided social interaction and support for dementia patients and their carers.
• 94 % patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the record in the preceding 12 months compared to the CCG and national average of 88%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
• Staff had a good understanding of how to support patients with mental health needs and dementia.

Updated 17 January 2017

The practice was rated as good for the care of people whose circumstances may make them vulnerable 28 April 2016. This rating remains unchanged

• The practice identified patients living in vulnerable circumstances
• The practice offered longer appointments for patients with a learning disability.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.