The Care Quality Commission
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Archived: Park Surgery

Overall: Good read more about inspection ratings

278 Stratford Road, Solihull, West Midlands, B90 3AF (0121) 241 1700

Provided and run by:
Park Surgery

All Inspections

29 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

This inspection at Park Surgery on 29 February 2016 was in follow up to our previous comprehensive inspection at the practice on 6 November 2014 (where the practice was rated as requires improvement overall but with safe rated as inadequate).

Four regulatory breaches of the Health and Social Care Act 2008 were identified. These breaches related to areas of risk management or assessment, infection control, recruitment processes and the practice processes for obtaining consent. Four requirement notices were issued and the practice subsequently submitted an action plan to CQC on the measures they would take in response to our findings.

At our inspection on 29 February 2016 we found that the practice had improved. We found that three of the four requirement notices we issued following our previous inspection had been met although one breach relating to risk assessment and management under safe care and treatment remained. However, the practice had improved enough for the practice ratings to have been updated to reflect our recent findings. The practice is now rated as good overall (with the safe domain now rated as requires improvement).

Our key findings across all the areas we inspected were as follows:

  • Staff we spoke with understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. We saw evidence to demonstrate that learning was shared amongst staff.
  • Risks to patients were assessed and managed, with the exception of those relating to the assessment of staff carrying out chaperoning duties. Not all staff who chaperoned had received chaperone training or a Disclosure and Barring Service check (DBS check). Nor had a risk assessment been carried out to make sure patients were protected. Risk assessments not being in place for some staff had also been identified as an issue at the last inspection on 6 November 2014. Post-inspection we received some information from the practice about how this was being corrected.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients we spoke with told us they were treated with compassion, dignity and respect and most patients also felt they were involved in decisions about their care and treatment.
  • Information about services and how to complain was available and easy to understand. For example, a poster and information leaflets were available in the patient waiting area as well as complaints form.
  • Some patients said they found it difficult to make an appointment with a named GP although urgent appointments were available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. There were disabled facilities, hearing loop and translation services available as well as ramped access. A bell was located at the front entrance doors so that wheelchair users were able to request assistance when required. Most consultations were held on the ground floor.
  • The practice had carried out clinical audits and re-audits to improve patient outcomes.
  • There was a clear leadership structure and staff we spoke with were motivated and felt supported by management. The practice had sought feedback from patients and had an active patient participation group in place.

The areas where the provider must make improvements are:

  • Ensure Disclosure and Barring Service check (DBS check) or risk assessments are in place for all staff involved in carrying out chaperoning and all staff undertaking chaperoning are provided with the appropriate training.

In addition the provider should:

  • Consider using the national patient survey results to identify areas of improvement. For example the processes for appointments to further identify potential opportunities to reduce appointment waiting times and improve patient access and experiences.
  • Consider reviewing the process for infection control and hygiene to ensure it is effective. For example to ensure that hand-gels are always available and soap dispensers were re-filled in both the staff and patient toilets.
  • Consider documenting verbal complaints in order to identify reoccurring themes or trends.
  • Consider how the practice can further improve the consent process to ensure appropriate consent is always recorded when required.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

6 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We completed a comprehensive inspection at the Park Surgery on 6 November 2014. Overall the practice is rated as required improvement.

We found that the practice was rated good for caring and responsive. However, we identified that the practice required improvement in providing an effective and well-led service. It was inadequate in respect of providing safe services.

We found the care provided to the six population groups (people with long term conditions, families, children and young people, working age people, older people, people in vulnerable groups and people experiencing poor mental health) also required improvements. The ratings for the population groups are due to the provider rating of requires improvement for effective and well-led and an inadequate rating in safe. The concerns that led to these ratings apply to everyone using the practice, including these population groups.

Our key findings were as follows:

  • Systems in place to manage and monitor the delivery of a safe service were in place but not robust.
  • The practice provided effective services to patients overall but required improvement to demonstrate valid consent was given for minor surgery and effective use of audit to deliver service improvement.
  • Patients were satisfied with the service overall and told us that they were treated with dignity and respect.
  • Access to appointments was in line with other practices nationally although patients raised this as their main concern.
  • Governance arrangements were not clearly defined resulting in inconsistent and ineffective management of risks.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure that robust systems are put in place to identify, monitor and manage risks to patients and others who use the service by undertaking assessment of potential risks and implementing appropriate monitoring in areas such as infection control, the safety of the premises and emergency equipment. Review the clinical audit process to ensure the outcome and findings support service improvement.
  • Ensure appropriate recruitment checks are undertaken to ensure that suitable staff are employed at the practice.
  • Ensure appropriate systems are in place to protect patients and others from the risks of health care associated infection.
  • Ensure consent for treatment is appropriately documented to demonstrate that risks, benefits and complications associated minor surgery have been explained and understood by the patient.

In addition the provider should:

  • Review how they gain assurance that staff have the necessary knowledge, skills and understanding in relation to their roles and responsibilities in the absence of training.
  • Ensure new staff have an effective induction programme so that they are aware fully of practice policies and procedures and location of equipment. Maintain up to date, practice specific policies and procedures in which staff can refer to in order to ensure consistency in the provision of services.
  • Ensure that all patients have easy access to details of the complaints process.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

31 October 2013

During a routine inspection

On the day of our inspection we spoke with a doctor, three members of staff and six patients.

All patients we spoke with were satisfied with every aspect of the surgery. This included the appointment system. When necessary patients were given an appointment for the same day. All patients said they could easily get through to the surgery by telephone. One said: 'I'm always able to get an appointment quickly and easily.'

We saw patients' views and experiences were taken into account in the way the service was provided and that they were treated with dignity and respect. When patients received care or treatment they were asked for their consent and their wishes were listened to.

The practice is located in a modern building. The ground floor is fully accessible for people with disabilities and this is taken into account when appointments are made for people who are unable to use stairs. There are disabled parking spaces close to the building in the car park.

We found the practice to be clean and well organised. Processes were in place to minimise the risk of infection. There were also processes in place for monitoring the quality of service provision. There was an established system for regularly obtaining opinions from patients about the standard of the service they received.