We carried out an announced inspection at Avenue Medical Practice on 17 and 27 June 2022. Overall, the practice is rated as Good.
The ratings for each key question are:
Safe - Requires Improvement
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
This is the first time we have inspected this practice under the current registered provider.
It was inspected under a different registered provider in October 2015 and was rated as good overall.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Avenue Medical Practice on our website at www.cqc.org.uk.
Why we carried out this inspection
This inspection was a comprehensive inspection to check how the practice was meeting essential standards and to inspect and rate it following the new registration with the Care Quality Commission.
- As this was an inspection of a new registration we inspected all five key questions. These are; is the practice safe, effective, caring, responsive and well led?
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 have rated this practice as Good overall
We rated the practice as requires improvement for being safe because:
- The process for handling of requests for repeat medicines and structured medicines reviews was not always effective.
- The practice had not ensured that some aspects needed to support good safeguarding arrangements were in place, for example, up to date policies and procedures; update training to the appropriate level for staff; and, regular formal multi-disciplinary (MDT) meetings.
We also found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- The practice were in the process of managing change, as a new provider was being commissioned to provide the service going forward.
- Some aspects of governance had not been prioritised during the pandemic. As we come out of the pandemic the practice had started to identify and address these areas to ensure the practice continued to operate effectively.
Whilst we found no breaches of regulations, the provider should:
- Review and improve the approach to conducting medicine reviews to ensure they are comprehensive and clearly document what was considered as part of the review. This includes considering the process for monitoring patients who have asthma to identify and address those who have high use of first step rescue medicines, which might indicate either misuse or an exacerbation of their asthma.
- Continue with the planned reintroduction of formal multi-disciplinary team meetings to support good communication between the practice and other healthcare professionals.
- Continue to implement and monitor the training plan to ensure staff have the relevant knowledge and skills required to do their job.
- Continue with the plan to review practice policies and procedures to ensure they reflect current guidance, regulations and best practice.
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