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Review carried out on 23 October 2019

During an annual regulatory review

We reviewed the information available to us about College Road Surgery on 23 October 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 14 November 2018

During a routine inspection

This practice is rated as Good overall. (Previous rating October 2017 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at College Road Surgery on 14 November 2018. This was as part of our inspection programme to ensure that improvements made previously had been maintained.

At this inspection we found:

  • 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 and reported that they were able to access care when they needed it.
  • There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Continue to take action to improve uptake for national cancer screening programmes.
  • Strengthen the oversight of safeguarding arrangements, including to formalise cover for the safeguarding lead role, and regular internal meetings.
  • Take action to provide annual medication reviews for patients prescribed more than one medicine.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection carried out on 5 October 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice


We carried out an announced comprehensive inspection at College Road Surgery on 18 February 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the 18 February 2016 inspection can be found by selecting the ‘all reports’ link for College Road Surgery on our website at www.cqc.org.uk. Following this inspection the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the breaches.

We carried out an announced comprehensive inspection following the period of special measures at College Road Surgery on 17 November 2016, this inspection was to verify if the practice had carried out their action plan to meet the legal requirements in relation to the breaches in regulations that we had identified in our previous inspection on 18 February 2016. We found that they had completed their action plan and made significant improvements and the practice was taken out of special measures, however there were still some areas of concern. Overall the practice was rated requires improvement. Following this inspection the practice sent to us an action plan detailing what they would do to improve performance in relation to the following:-

  • Ensure patients with long term conditions receive the best care.
  • Improve the uptake of childhood immunisations and national screening programmes.
  • Review and improve patient satisfaction

This report covers our findings in relation to the announced focussed inspection carried out on 5 October 2017. The full comprehensive report on the 18 February 2016 and the focused follow up report on the 17 November 2016 inspection outcomes can be found by selecting the ‘all reports’ link for College Road Surgery on our website at www.cqc.org.uk.

Our key findings were as follows:

  • The practice was working with the patient participation group and other external groups to help engage patients in their care.
  • The practice has introduced a number of alternative methods of communications; for example; easy read guides, Urdu speaking GPs, leaflets in multiple languages, and a form for booking follow up appointments which is completed by a clinician.
  • Processes to ensure patients with long term conditions received the best care had been reviewed and new processes put in place.
  • The uptake of childhood immunisations and national screening programmes had been reviewed and new processes had been put in place to increase uptake.
  • The practice continued to review and improve patient satisfaction.

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

The provider should:

  • Continue to monitor and improve patient satisfaction.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 17/11/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at College Road Surgery on 18 February 2016. The practice was rated as inadequate for providing safe, effective, caring, responsive and well-led services. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the February 2016 inspection can be found by selecting the ‘all reports’ link for College Road Surgery on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 17 November 2016. Overall the practice is now rated as requires improvement.

Our key findings were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect; although some said that staff could be dismissive and they did not always feel they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it difficult to make an appointment with a GP of their choice but urgent appointments were available the same day.
  • The practice had good facilities and was 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.

We saw one area of outstanding practice:

The practice had a large number on non- English speakers on their practice list. In order to ensure that patients understood the consent questions that they were asked, the practice provided audio recordings of these consent questions. These questions were provided in the four main languages used by patients; Urdu, Punjabi, Hindi and Polish.

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

The provider should:

  • Continue to review processes to ensure patients with long term conditions receive the best care.
  • Continue to review and improve the uptake of childhood immunisations and national screening programmes.
  • Continue to review and improve patient satisfaction.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 18 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at College Road Surgery on 18 February 2016. Overall the practice is rated as inadequate.

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

  • Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, the practice could not demonstrate that all incidents were recorded, that reviews and investigations were thorough enough or that learning was shared effectively with staff.
  • Risks to patients were not all assessed or well managed for example no Legionella risk assessment had been completed.
  • Data showed patient outcomes were mixed compared to local and national patient outcomes. Evidence was hard to identify as little or no reference was made to audits or quality improvement and there was little evidence that the practice was comparing its performance to others; either locally or nationally.

  • The majority of patients said they were treated with compassion, dignity and respect. However, not all felt cared for, supported and listened to.
  • Information about services was available but not everybody would be able to understand or access it.

  • Urgent appointments were usually available on the day they were requested

  • The practice had a number of policies and procedures to govern activity.

The areas where the provider must make improvements are:

  • Introduce robust processes for reporting, recording, acting on and monitoring significant events, incidents and near misses and ensure that lessons learnt from complaints and significant events are communicated to the appropriate staff to support improvement.
  • Ensure that all building risk assessment and safety checks are completed including gas safety checks and Legionella risk assessments.
  • Ensure that the actions identified from risk assessments are completed including infection control and fire safety risk assessments.
  • Carry out clinical audits and re-audits to improve patient outcomes and to ensure improvements have been achieved.
  • Ensure that a robust system is put in place for acting on correspondence from external sources such as hospitals including pathology results and medicine changes.
  • Ensure that emergency equipment including oxygen is stored in an appropriate location that is easily accessible to all staff.
  • Ensure that appropriate training is completed including Mental Capacity Act and ensure that all staff understand the relevant consent and decision-making requirements of legislation.
  • Ensure that they have done everything reasonably practicable to provide safe care and treatment to patients whose first language is not English due to the practice telling us their population is 86% Urdu speaking who do not have English as their first language.
  • Review the risks of using friends and family to translate and as advocates at times of obtaining consent and providing treatment because of the risk of them biasing the consultation.

  • Ensure that patient privacy is maintained at all times including that doors close properly and staff can not be overheard in the waiting room.
  • Ensure that disabled facilities are adequate to meet the needs of their patient group.
  • Ensure that the process to register a manager with CQC for this location is completed.

In addition the provider should:

  • Improve the availability of non-urgent appointments.

  • Provide practice information in appropriate languages and formats.

  • Review their exception reporting criteria and practice performance to improve patients outcomes.

  • Review and update procedures and guidance.

  • Review and improve where possible confidentiality for patients.
  • Conduct an up to date fire risk assessment.
  • Review the emergency medicines held on site and the management of these.

I am placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The practice will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service.

Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice