Thornbury Road Centre for Health

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions safe, effective, responsive and well-led. The rating for the key question caring would be carried through from the previous inspection conducted in 2016. We carried out the previous inspection on 2 August 2016 and rated the practice as good overall.

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 and requires improvement overall for all population groups.

We rated the practice as r equires improvement for providing safe and responsive services because:

• Risks to patients were not assessed and well managed in relation to the spread of infections to the patients and staff, frequency of fire drills and the management of legionella.
• We found an expired emergency medicine and the practice had not maintained a log to monitor the expiry dates.
• We noted the practice was not always segregating clinical waste into appropriate colour-coded containers.
• Safeguarding children policy was reviewed, but it did not include up to date details.
• The practice did not have any formal monitoring system in place to assure themselves that blank prescription forms were recorded correctly, and records were maintained as intended.
• Feedback from patients reflected that they were not always able to access care and treatment in a timely way.
• The practice was encouraging patients to register for online services and 52% of patients were registered to use online Patient Access.
• Information about services and how to complain was available.

We rated the practice as good for providing effective and well-led services because:

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided.
• The practice’s uptake of the cervical cancer screening rates was below the national average and they had the high inadequate rate for smear results, which were not formally discussed, and learning was not shared with the relevant staff.
• The practice was aware of and complied with the requirements of the Duty of Candour.
• There was a clear leadership structure and staff felt supported by the management.
• The practice had demonstrated good governance in most areas, however, they were required to make further improvements.

We rated all population groups as requires improvement for providing responsive services. We rated all population groups as good for providing effective services, with the exception of working age people (including those recently retired and students) which is rated as requires improvement, because of low cervical cancer screening rates and the high inadequate rate for smear results.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• 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).

The areas where the provider should make improvements are:

• Review training update arrangements in relation to childhood and travel immunisations and dementia awareness.
• Continue to encourage and monitor childhood immunisation uptake rates.

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