This practice is rated as Good overall. (Previous rating under a different provider September 2015 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive at Clarence Park Surgery on 17 October 2018 as part of our inspection programme.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

• The provider must continue with the development of the overarching health and safety management including fire safety.
• The provider must take measures to help manage the risks associated with sepsis - conducting staff training in recognising and responding to acutely unwell or deteriorating patients
• The provider needs to continue to develop how it records significant event management and complaints to monitor themes and trends and to ensure that actions put in place are effective to prevent reoccurrence.

The areas where the provider should make improvements are:

• The provider should continue with developing a central oversight of staff’s immunisation status to ensure that staff and patients were protected from the spread of infection.
• The provider should continue with the changes put in place to the external security of clinical waste so that it could not be tampered with or removed from the premises by unauthorised people.
• The provider should continue with an effective programme to ensure that patients with mental health needs and dementia have the necessary reviews and care plans in place 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• The provider should continue with developing an effective monitoring system so that out of date information and instructions such as patient group directions for the provision of immunisations are removed and replaced when required.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.