The Care Quality Commission
  • Doctor
  • GP practice

Addington Road Surgery

Overall: Good read more about inspection ratings

77 Addington Road, West Wickham, Kent, BR4 9BG (020) 8462 5771

Provided and run by:
Addington Road Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Addington Road Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Addington Road Surgery, you can give feedback on this service.

23 July 2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Addington Road Surgery on 29 June 2016. The rating for the safe was requires improvement and all other key questions the rating was good. The full comprehensive report can be found by selecting the ‘all reports’ link for Addington Road Surgery on our website at www.cqc.org.uk.

An announced follow-up inspection was carried out on 25 July 2018. Overall the practice was rated as good. The rating for the effective key question was requires improvement.

This inspection was an announced focused inspection carried out on 23 July 2019, looking at effective key question, to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 25 July 2018.

At this inspection we found that improvements had been made. Our key findings across the area inspected is as follows:

  • 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.
  • Childhood immunisation uptake rates were below the World Health Organisation (WHO) targets.
  • The Quality and Outcomes Framework (QOF) data from 2017/18, showed that the practice performance was still below the local and national average for several clinical indicators. Unverified results for 2018/19 provided by the practice showed an improvement in the areas identified as requiring improvement at the last inspection for example patients with mental health, asthma and diabetes indicators had improved and were now comparable to local and national averages.
  • Since the last inspection, the provider had undertaken two full cycle clinical audits which demonstrated quality improvement for patients.
  • Since the last inspection, the practice had devised an action plan and had recruited several staff members and created key roles to aid in providing effectives services for patients.

The practice remains rated good overall.

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

The areas where the provider should make improvement are:

  • Continue to monitor and review uptake of childhood immunisations.

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

Care.

During a routine inspection

This practice is rated as Good overall. (Previous inspection 29 June 2016- (Rated Good overall Requires Improvement in Safe)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Addington Road Surgery on 29 June 2016 to follow up on previously identified breaches of regulations. We inspected the practice at 77 Addington Road, West Wickham BR4 9BG. The overall rating for the practice following that inspection was Good. The full comprehensive report on the 29 June 2016 inspection can be found by selecting the ‘all reports’ link for at Addington Road Surgery on our website at www.cqc.org.uk

We carried out an announced comprehensive inspection at Addington Road Surgery on 25 July 2018 to follow up on breaches of regulation identified in June 2016.

At this inspection we found:

  • All staff had received role specific training including basic life support, safeguarding and fire safety.
  • The recruitment process had been reviewed and was now effective and in line with relevant legislation.
  • The practice had reviewed patient satisfaction in relation to telephone access and the practice had undertaken their own patient survey, however this was an area the practice acknowledged still needed to be developed.
  • The practice had reviewed how they made complaint forms accessible to patients.
  • Access to services and appointments had been reviewed and improved to support improvements in patient satisfaction and was still being revised.
  • 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, however reported that they had difficulties accessing appointments when needed.
  • Data for 2016/2017 showed several patient outcomes were below local and national averages in relation to the Quality and Outcomes Framework clinical targets. The practice provided evidence for 2017/2018 that clinical performance had improved but this data had not been independently verified or published at the time of our inspection.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

  • Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences.

The areas where the provider should make improvements are:

  • Review registration details so they are fully updated.
  • Review process for undertaking fire risk assessment.
  • Continue to review accessibility and appointments.
  • Review updating the practice leaflet and how accessible it is.

29 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Addington Road Surgery

on 29 June 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 a system in place for reporting and recording significant events; however, the significant events policy could not be located during the inspection.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Not all staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. There were gaps in mandatory training that staff did not complete.
  • 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 on practice website and easy to understand; however, no leaflets were visible in the practice, patients had to request the practice complaints procedure leaflet.
  • 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 improvement are:

  • Ensure that all staff have received mandatory training including basic life support, safeguarding and fire safety.

  • Ensure that the recruitment process is effective and in line with relevant legislation.

The areas where the provider should make improvement are:

  • Review patient satisfaction GP survey on telephone access.

  • Review how they make complaints forms accessible to patients.

  • Ensure patient access to services and appointments are reviewed and improved to support improvements in patient satisfaction.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice