22 September 2015
During a routine inspection
We carried out an announced comprehensive inspection at Clarence Road Surgery on 22 September 2015. Overall the practice is rated as inadequate.
Specifically, we found the practice inadequate for providing safe and well-led services. Improvements were also required for providing effective and responsive services. The concerns which led to these ratings apply to all the population groups we inspected. The practice was good for providing caring services.
Our key findings across all the areas we inspected were as follows:
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Patients were at risk of harm because the systems and processes in place did not always ensure the safety of people using and / or accessing the service. For example, the premises had not been regularly maintained to protect people from harm and some of the identified actions to address concerns with infection control practices and health and safety had not been implemented.
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The practice premises did not have suitable facilities to treat patients and meet their needs.
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Staff understood and fulfilled their responsibilities to raise concerns and to report significant events and near misses. However, information about safety was not always recorded, monitored, appropriately reviewed and addressed.
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Most patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
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Patients’ needs were assessed and care was planned and delivered following best practice guidance.
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Urgent appointments were usually available on the day they were requested. Some patients said they sometimes had to wait a long time for non-urgent appointments and that it was difficult to get through the practice when phoning to make an appointment in the morning.
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Nationally reported data showed most of the patient outcomes were comparable or above average locally and nationally.
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Clinical audits were driving improvements to patient outcomes.
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Non-clinical staff had received training that was appropriate to their roles and further training needs had been identified and planned.
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However, not all practice nurses were supported with formal supervision and appraisal.
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Information about services and how to complain was available and easy to understand.
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The practice had a virtual patient participation group in place. However engagement was limited to the practice survey, results and discussions around patient demand for appointments.
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The overarching governance framework in place did not always operate effectively or support the delivery of good quality care.
The areas where the provider must make improvements are:
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Ensure action is taken to address identified concerns related to the premises and infection prevention and control practices. This includes staff training, immunisation status and audits.
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Ensure formal governance arrangements are robust and implemented in practice. This includes systems for assessing and monitoring health and safety risks and the quality of the service provision.
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Ensure there is a clear vision, detailed and realistic strategy as well as leadership capacity to deliver all the improvements.
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Ensure all staff are supported with induction, supervision and appraisal.
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Ensure serial numbers are recorded for prescriptions kept in the doctor’s bag.
The areas where the provider should make improvement are:
- Ensure all staff undertaking chaperoning duties receive refresher training and are fully aware of their responsibilities.
- Improve processes for phone access and making non-urgent appointments.
- Ensure patient records are scanned and accessible from the electronic system in a timely way.
On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.
Professor Steve Field CBE FRCP FFPH FRCGP