27 May 2021
During an inspection looking at part of the service
We carried out an announced focused inspection at Mitchley Avenue Surgery on 27 May 2021 and a remote clinical review on 26 May 2021 to follow up on breaches of regulations. Overall, the practice was rated as requires improvement.
The practice was previously inspected on 11 September 2019. Following that inspection, the practice was rated as requires improvement overall (requires improvement in safe and well-led) for issues in relation to recruitment checks; safety systems and records; risk assessments for patients; medicines management; management of significant events; staff training and appraisals and governance arrangements.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Mitchley Avenue Surgery on our website at www.cqc.org.uk
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
- Completing 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
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 rated the practice as Inadequate for providing safe services.
At this inspection, we found the provider had made some improvements in providing safe services. In particular, the provider had made improvements to their systems and process in relation to maintenance of equipment and checks, learning from significant events and complaints and maintenance of recruitment records for staff. However, we found new issues in relation to safeguarding, infection prevention and control and medicines management.
We rated the practice as good for providing effective services.
At this inspection, we found the provider had assessed patients’ needs and that care and treatment was delivered in line with current legislation. However, the quality outcomes for patients with diabetes were below average.
We rated the practice as requires improvement for providing well-led services.
We found the provider had made improvements in providing well-led services in relation to good governance and had implemented systems and process in response to the findings of our previous inspection. However, governance arrangements in place still required improvement especially in relation to identifying, managing and mitigating risks.
We have rated this practice as requires improvement overall and requires improvement for population group people with long-term conditions.
The areas where the provider must make improvements are:
- Ensure that care and treatment is provided in a safe way for patients.
- Establish effective systems and processes to ensure good governance in accordance with fundamental standards of care.
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
- Improve practice process for training of staff on identifying deteriorating or acutely unwell patients.
- Improve outcomes for patients with diabetes.
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