07 October 2014
During a routine inspection
Letter from the Chief Inspector of General Practice
We undertook a comprehensive inspection of Addiscombe Road Surgery on 07 October 2014. The provider, Dr Bellanage Sunanda Jayaratne, has a branch surgery to Addiscombe Road Surgery, 139 Northway Road Surgery, which is also in Croydon. We did not visit the branch surgery as part of this inspection.
We found that overall Addiscombe Road Surgery was rated as requires improvement. We found them Good in the Caring, Responsive and Well Led domains, but there were areas of the Safety and Effectiveness domains that required improvement.
Our key findings were as follows:
- The practice referenced published best practice guidelines and the local clinical commissioning group guidelines in ensuring positive health outcomes for patients.
- The practice used the Quality and Outcomes framework to measure, monitor and improve performance. The practice was performing well against most indicators compared to other practices in the area and against national averages.
- The practice was well-led and its predominantly long serving staff team felt valued and supported. The staff team displayed a real sense of pride in the work they did.
- The practice had an active patient participation group, members of which praised the support they had received from the practice team and how well the practice responded to their suggestions
- Patients consistently reported good experiences of the care and treatment they had in the practice, and felt the entire staff team contributed in one way or another to their care.
However, there were also areas of the practice where the provider needs to make improvements.
Importantly, the provider must:
- Ensure the recruitment policy is followed fully in the recruitment of new staff
In addition, the provider should:
- Ensure clinical audit cycles are completed to determine if improvements had been maintained
- Ensure full job descriptions are in place for all members of the staff team, so that staff are clear about their role and responsibilities.
- Ensure records of the checks of the oxygen cylinder are maintained
- Ensure it takes active steps to increase its flu vaccinations uptake in order to meet set targets.
- Ensure formal training is provided to the practice’s safeguarding lead to support them in performing that role
- Ensure the practice vision and values are shared from the leadership team with the practice staff team and patients.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice