Background to this inspection
Updated
17 May 2019
The Locality Health Centre CIC is the registered provider of Clarence Park Surgery. The Locality Health Centre CIC is a community interest company based in Weston Super Mare which also provides another GP service in the local area. Clarence Park Surgery is provided from one address, 13 Clarence Road East, Weston Super Mare, BS23 4BP and delivers a personal medical service to approximately 4,864 patients. The practice is situated in an adapted building in a residential area, with limited parking. Information about Clarence Park Surgery can be found on the practice website www.clarenceparksurgery.co.uk.
According to information from Public Health England the practice area population is in the fourth most deprived decile in England. The practice population of children is below local and national averages at 15%. The practice population of working age at 47% is below local and national averages at 62%. The practice population of patients living with a long-term condition was above the local and national averages at 75%, the local being 53% and national being 54%. Of patients registered with the practice, 96% are White or White British, 1.7% are Asian or Asian British, 0.6% are Black or Black British, and 1.1% are mixed race and Other 0.4%.
The provider has told us the practice team is made up of four salaried GPs one being the Clinical Lead for the provider. which means overall the practice has the equivalent of 2.06 WTE (whole time equivalent) GPs at the practice. Three advanced nurse practitioners (ANP) equivalent to 1.5 WTE, three practice nurses equivalent to 1.2 WTE and one health care assistant. The registered manager (RM), who is the RM for both locations is the Chief Executive of the organisation. The practice manager and the deputy manager are responsible for both locations the organisation has and are supported by a team of administrators, secretaries, and reception staff.
When the practice is not open patients can access treatment via the NHS 111 service.
The practice provides family planning, surgical procedures, maternity and midwifery services, treatment of disease, disorder or injury and diagnostic and screening procedures as their regulated activities.
Updated
17 May 2019
We carried out an announced focused inspection at Clarence Park Surgery on 2 April 2019. This inspection was carried out to follow up on breaches of regulations and areas identified for improvement where we had rated the key question of well led as requires improvement. We had implemented one regulatory requirement, Regulation 17- Good governance and identified areas the provider should take action to improve.
This practice is rated as Good overall. (Previous rating November 2018 – Good)
Are services safe? – Good
Are services effective? – Good
Are services well led? – Good
The patient population groups were all rated as Good.
These were highlighted in the aspects of the areas of safe and well led:
The provider was required to:
- Ensure patients with mental health needs and dementia had the necessary reviews and care plans in place to meet their needs, manage the risks associated with sepsis, including training for staff, the management of significant event management and complaints to monitor themes and trends.
We had also identified areas the provider should make improvements:
- Central oversight of staff’ immunisation, change external security of clinical waste so that it could not be tampered with or removed from the premises.
- Continue with an effective programme to ensure that patients with mental health needs and dementia have the necessary reviews and care to meet their needs.
- The provider should continue with developing an effective monitoring system so that out of date information and instructions such as patient group directions for the provision of immunisations are removed and replaced when required.
At this inspection we reviewed the areas of safe and well led. We included effective as the information we had about the practice indicated potential changes and wished to assess this didn’t compromise meeting patient’s needs. We found:
- A new system of assessment and management of health and safety had been implemented which needed to be fully embedded and sustained.
- Improvements to seek information and confirmation of staff immunisation status was in progress but not yet completed.
- Changes in some of the aspects of infection control had been implemented including security of clinical waste. However, infection control audits were not detailed and had not picked up issues such as appropriate storage of mops and disposable goods in line with current guidance.
- The storage of medicines was not secure, such as clear stock monitoring and safe storage of medicines keys.
- Staff had been trained to respond to medical emergencies – identifying patients at risk from sepsis.
- The management and oversight of significant events and complaints had been strengthened with the improved recording and monitoring.
- The new IT information management system had supported staff to maintain a clear oversight of risks, schedules and monitoring for areas including recruitment, employment and management of areas such as patient group directions for the delivery of vaccinations and immunisations.
- There was an improved monitoring and a programme of support for patients with mental health needs and dementia.
The areas where the provider should make improvements are:
- The provider should continue with developing a central oversight of staff immunisation status to ensure that staff and patients were protected from the spread of infection.
- The provider should continue with a sustained effective programme to ensure that patients have the necessary reviews and care plans in place to meet their needs.
- Ensure the new system of assessment and management of health and safety was embedded and sustained.
- The oversight of infection control management and medicines should be reviewed to ensure it is secure and the system for monitoring medicine stock is improved.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
Please refer to the detailed report and the evidence tables for further information.