- GP practice
Archived: Queens Avenue Practice
All Inspections
19 July 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 Queens Avenue Practice (also known as Queens Avenue Surgery) on 7 September 2016. The overall rating for the practice was Requires Improvement. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for Queens Avenue Practice on our website at www.cqc.org.uk.
At our previous inspection in September 2016, we rated the practice as Requires Improvement for providing safe and well-led services. At this time included amongst the issues we identified, was the practice did not have adequate management and storage of medicines held on site and that infection control processes were not effective enough to keep patients safe. In addition, we found that not all of the practice policies, procedures and guidance had been reviewed recently and that no staff had received recent information governance training.
This inspection was an announced focused inspection carried out on 19 July 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 on 7 September 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. At this inspection, we found that the practice had made improvements to provide safe and well-led services. As a result of these findings, the practice is now rated as good for providing safe and well-led services.
The change in the ratings for the key questions of safe and well-led, means that the practice is now rated as good overall.
Our key findings were as follows:
- Risk to patients were assessed and managed correctly. For example, all vaccines kept at the practice were stored in pharmacy refrigerators.
- The surgery had conducted a review of all policies and procedures which governed activity within the practice.
- The practice had effective infection control processes in place and these were primarily monitored by members of the clinical team, but also by the wider team at the practice.
- There was a clear governance structure at the practice, led by the senior GP partner who was supported by a second GP partner.
- The practice reviewed its provision of nursing services, and as a result now employed a practice nurse who conducted sessions two times a week.
- We saw evidence that staff had conducted relevant training such as information governance training and childhood immunisation training for clinical staff.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
7 September 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Queens Avenue Surgery on 7 September 2016. Overall the practice is rated as Requires Improvement.
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.
- There was a lack of overall governance by the partners at the surgery.
- Risks to patients were assessed and but not always managed correctly. For example, the storage of some vaccines were contained in a domestic refrigerator which was not temperature monitored.
- Patients said they were treated with compassion, dignity and respect.
- The surgery did not have effective infection control processes in place. This was evidenced on the day of inspection as the inspection team witnessed the storage of medical devices in a visibly unclean container.
- The surgery had a number of policies and procedures to govern activity, but some were overdue a review.
The areas where the provider must make improvements are:
- Ensure that all vaccines used are stored appropriately and that all medical devices are stored and cleaned to appropriate infection control standards.
The areas where the provider should make improvements are:
- Review and update surgery policies, procedures and guidance.
- Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is available to them.
- Identify a suitable accessible location for the storage of emergency oxygen held at the surgery.
- Conduct disability assessment audit regarding the lack of a disabled toilet at the surgery.
- Ensure that all staff undertake Information Governance training.
- Review arrangements for the adequate provision of nursing services.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
7 March 2014
During a routine inspection
"Brilliant", "never had a problem", "nothing but praise", "always able to get emergency appointment" and "the care and attention given is good" were a few of the comments people made. The things people felt the practice did well were: team work; courteous staff; good system for repeat prescriptions and they said "patients get good treatment that is tailored to their needs". We were told that people appreciated that it was a small practice with family values. There was a general consensus that making appointments was not an issue. People said the waiting room and consultation rooms were always clean. The practice had a patient participation group that had met twice a year, members of the group felt that it gave doctors "the patient perspective".
Staff were happy to be working at the practice and said that they had the training and support they needed and were aware of their roles and responsibilities.
We saw that procedures were in place for safeguarding children and vulnerable adults and staff demonstrated that they were aware of their responsibilities. Medicines were stored and managed correctly. Suitable systems were in place for the prevention of cross infection.