The Care Quality Commission
  • Doctor
  • GP practice

Dr Sarah Johnson and Partners Also known as Alma Road Surgery

Overall: Good read more about inspection ratings

Alma Road, Romsey, Hampshire, SO51 8ED (01794) 513422

Provided and run by:
Dr Sarah Johnson and Partners

Important: We are carrying out a review of quality at Dr Sarah Johnson and Partners. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

14 July 2023

During a routine inspection

We carried out an announced inspection at Dr Sarah Johnson and Partners (also known as Alma Road Surgery) on 14 July 2023. Overall, the practice is rated as Good.

Following our previous inspection in August 2021, we issued a Warning Notice for Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment, and rated the practice as Requires Improvement overall and for 2 key questions: are services Safe and Well-Led. We rated the remaining 3 key questions, are services Effective, Caring and Responsive as Good.

At this inspection, we found that significant improvements had been made, specifically in the management of medicines, monitoring and reviewing patients with long term health conditions and the system to manage safety alerts. We have rated this practice as Good overall. Specifically, we have rated the practice as:

Safe – Good

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Alma Road Surgery on our website at www.cqc.org.uk.

Our findings

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 found that:

The practice had made considerable improvements since our previous inspection in August 2021:

  • All of the concerns from the previous inspection had been adequately addressed and there were no longer any breaches of regulations.
  • 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.
  • The practice was able to demonstrate staff had the skills, knowledge and experience to carry out their roles. Staff members were appraised annually and received appropriate supervision and training.
  • The practice provided a personal named GP list system to promote consistency and continuity for its patients.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

Whilst we found no breaches of regulations, the provider should:

  • Continue to improve cervical screening uptake rates.
  • Continue to work with patients to form an active patient participation group.
  • Continue to identify and support carers.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

6 August 2021

During a routine inspection

We carried out an announced inspection at Dr Sarah Johnson and Partners (also known as Alma Road Surgery) on 6 August 2021. Overall, the practice is rated as Requires Improvement.

Following our previous inspection on 12 March 2019, the practice was rated Requires Improvement overall and for three key questions, specifically Safe, Effective and Well-Led. We rated the remaining two key questions Caring and Responsive as Good.

At this inspection, we found that whilst some improvements had been made, the provider was still not compliant with Regulation 12 Health and Social Care Act 2008 (Regulated Activities) (HSCA RA) Regulations 2014 which relates to safe care and treatment. We have rated this practice as Requires Improvement overall. Specifically we have rated the practice as:

Safe – Requires Improvement

Effective - Requires Improvement

Caring - Good

Responsive - Good

Well-led - Requires Improvement

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Alma Road Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

Due to reported concerns from the March 2019 inspection, we issued a requirement notice for Regulation 12 HSCA (RA) Regulations 2014.

We carried out an announced inspection on 6 August 2021 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 2019.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing facilities
  • Completing remote clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit
  • Discussions with practice staff

Our findings

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 found that:

  • The practice had made some improvements since our previous inspection in March 2019.
  • Systems had been strengthened to ensure training registers were in place and monitored effectively. All staff had undertaken all mandatory training appropriate to their role.
  • Recruitment files contained all relevant information.
  • Prescription stationery was now stored securely and there was a monitoring system in place.
  • Risk assessments were in place for staff who did not require Disclosure and Barring Service checks.
  • The practice had made adjustments associated with the COVID-19 pandemic to ensure that patients were kept safe and protected them from avoidable harm.
  • The practice was able to demonstrate staff had the skills, knowledge and experience to carry out their roles. Staff members were appraised annually and received appropriate supervision and training.
  • The practice provided a personal named GP list system to promote consistency and continuity for its patients.
  • 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.
  • However, the practice did not provide care in a way that kept patients safe and protected them from avoidable harm. For example, regular reviews and monitoring for patients prescribed high risk drugs had not been completed in line with national guidance.

We found a breaches of one regulation. The provider must:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

In addition, the provider should:

  • Continue to improve cervical screening uptake rates.
  • Work with patients to form an active patient participation group.
  • Continue to identify and support carers.

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

12 March 2019

During a routine inspection

We carried out an announced comprehensive inspection at Alma Road Surgery on 12 March 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 requires improvement overall.

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

  • The practice could not provide us with the appropriate evidence to demonstrate GPs were appropriately trained in safeguarding children and vulnerable adults.
  • The practice did not have appropriate systems in place for the security and monitoring of prescription stationery.
  • Recruitment procedures were not consistently implemented.
  • Limited oversight of the full loop closure of safety alerts.

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

  • The practice could not provide adequate assurances that all GPs were appropriately trained in relation to Mental Capacity Act 2005 or Deprivation of Liberty Safeguards.
  • The practice could not provide adequate assurances that all staff were appropriately training in relation to Information Governance.

We rated the practice as requires improvement for providing well-led services because:

  • Systems and processes were not effectively established to ensure compliance with the requirements to demonstrate good governance. For example, there was a lack of oversight of GP training, prescription stationery security, safety alerts, and Disclosure and Barring Service checks.

We rated the practice as good for providing caring and responsive services because:

  • The practice provided a personal named GP list system to promote consistency and continuity for its patients.
  • 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.

These areas affected all population groups so we rated all population groups as requires improvement.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • 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.

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

The areas where the provider should make improvements are:

  • Improve the identification of carers to enable this group of patients to access the care and support they need.

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

18 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Alma Road Surgery on 18th November 2014. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services to all its patients in a safe environment. The practice is also rated as good for the six population groups which are older people, people with long term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

The practice was above average for its satisfaction scores on consultations with doctors and nurses with 98% of practice respondents saying the GP was good at listening to them and 96% saying the GP gave them enough time.

Data from the national patient survey showed 91% of practice respondents said the GP involved them in care decisions and 93% felt the GP was good at explaining treatment and results. Both these results were above average when compared to the CCG area.

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.
  • The practice delivered effective end of life care in line with the gold standards framework.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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 they found it easy to make an appointment with their named GP and that 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 practice had a positive relationship with the patient reference group.

Area of outstanding practice:

  • The practice had well developed systems for childrens safeguarding which was appropriately integrated with partner agencies to support the protection of vulnerable children and young people.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice