15/03/2018
During a routine inspection
We previously carried out an announced comprehensive inspection at College Road surgery on 27 June 2017. The overall rating for the practice was Good. The full comprehensive report on the 21 July 2017 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 an announced Comprehensive inspection carried out on 15 March 2018. This report covers our findings in relation to this inspection.
This practice is rated as Requires Improvement overall.
The key questions are rated as:
Are services safe? – Requires Improvement
Are services effective? – Requires Improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires Improvement
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Requires Improvement
People with long-term conditions – Requires Improvement
Families, children and young people – Requires Improvement
Working age people (including those recently retired and students – Requires Improvement
People whose circumstances may make them vulnerable - Requires Improvement
People experiencing poor mental health (including people with dementia) - Requires Improvement
At this inspection we found:
- There were areas where systems for identifying and managing risks had not been established, for example fire risk assessment.
- The systems for monitoring training were present but were not effective. For example, we found that not all clinical staff completed training which the practice identified as mandatory.
- The practice had systems around complaints but these were not always effective and were not used as opportunities for learning.
- We found that exception reporting at the practice was high in a number of areas. (Exception reporting relates to patients on a specific clinical register who can be excluded from individual QOF (Quality and Outcomes Framework) indicators. For example, if a patient is unsuitable for treatment, is newly registered with the practice or is newly diagnosed with a condition.) The practice had recently become aware of this and had established a coding issue in their registers and had begun actions rectify to this.
- National patient GP survey data for the practice was generally good overall. The practice were aware of areas that were highlighted as being lower than others and practice had taken some action to start to address this, for example, the practice had increased hours to improve access for patients.
- The practice accommodated a range of languages other than English appropriate to their population group.
The areas where the provider must make improvements are:
- Ensure care and treatment is provided in a safe way to patients.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment and ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
The areas where the provider should make improvements are:
- Develop a plan to improve the uptake of national screening programs such as cervical, breast and bowel screening.
- Continue to improve uptake of childhood immunisations in line with national standards and targets.
- Continue to proactively identify and support carers in line with national standards.
- Develop a plan to respond to issues identified from national GP patient surveys to improve patient satisfaction.
- Review the locum induction pack to ensure it is practice specific.
- Consider further ways to raise patient awareness in relation to access to appointments via the Hub.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice