Archived: Priory Avenue Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection of the Priory Avenue Surgery, 2 Priory Avenue, Caversham, Reading, Berkshire, RG4 7SF on the 29 July 2015. We carried out this inspection to check that the practice was meeting the regulations and to consider whether sufficient improvements had been made.

Our previous inspection in November 2014 found breaches of regulations relating to the safe and effective delivery of services. There were also concerns and regulatory breaches relating to the management and leadership of the practice, specifically in the well led domain. The overall rating of the practice in November 2014 was inadequate and the practice was placed into special measures for six months. Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance.

At the inspection in July 2015, we found the practice had made significant improvements since our last inspection in November 2014 and that they were meeting two for the four regulations which had previously been breached. The ratings for the practice have been updated to reflect our findings.

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

• Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses. Information about safety was recorded, monitored, and appropriately reviewed and addressed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• Patients said they were treated with compassion, dignity and respect and that they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• There was a leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.
• Recruitment checks for staff required improvement and documented evidence of these checks were not always recorded on staff files.
• Governance systems and processes required further improvement to monitor and assess the whole service in relation to risk and improvements.
• The practice was supported by mostly locum GPs, which may pose a risk to the continuity of care for patients and the leadership and management of the practice.

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

Importantly, the provider must:

• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Implement an effective system to ensure all complaints are responded to and outcomes and actions recorded.

In addition the provider should:

• Embed and maintain a continuous clinical audit programme.
• Ensure robust systems are in place to sustain current staffing levels at all times.
• Ensure all risks are assessed and actions followed up. For example, the risk assessment around the safety of the building and patients accessing first floor consultation rooms.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice