We carried out an announced comprehensive inspection at Headstone Road Surgery on 12 February 2019 as part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall, including all population groups.

We rated the practice as requires improvement for providing safe services because:

• The practice did not have effective systems and processes to keep patients safe. This included, fire safety and health and safety risk assessments.
• The practice did not have appropriate systems in place for the safe management of some medicines.
• The facilities were not always appropriate for the services being delivered. The practice could not accommodate both wheelchair users and mothers with pushchairs due to space constraints.
• There was no disabled patient toilet and the one patient toilet was not wheelchair friendly. There were no grab rails for patients with mobility issues, or an emergency call button.
• The practice did not have an effective system to learn and make improvements when things went wrong.

We rated the practice as requires improvement for providing effective services because:

• Not all staff could demonstrate the skills, knowledge and experience to carry out their roles. For example, not all staff were aware of the principles of obtaining consent in adults lacking capacity and could not undertake contraceptive reviews effectively.
• The practice had not identified that an error relating to a childhood immunisation while registered at another practice.

These areas affected all population groups so we rated all population groups as requires improvement.

We rated the practice as requires improvement for providing well-led services because:

• There were gaps in overall governance arrangements.
• Facilities were not always appropriate for the service being delivered.
• The practice did not have clear and effective processes for managing risks, issues and performance.

We rated the practice as good for providing caring and responsive services because:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Information leaflets were available in other languages and in easy read format.
• Patients were able to access care and treatment in a timely way.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Clearly identify where to locate the safeguarding contacts on the safeguarding policies. 
• Monitor that Patient Group Directions are signed by relevant staff on receipt or during new staff induction.
• Continue to monitor and improve on patient satisfaction in relation to feeling involved in their care.  
• Consider displaying bereavement leaflets around the practice.
• Install a hearing loop at the practice.
• Implement the whistle blowing policy in line with the NHS Improvement Raising Concerns (Whistleblowing) Policy.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Headstone Road Surgery on 7 January 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

• Ensure there is a risk assessment in place to demonstrate how they would be able to immediately respond to the needs of a person who becomes seriously ill on their premises, without access to a defibrillator.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Our inspection of 15 November 2013 found that people were being cared for in a clean and hygienic environment, however cleaning schedules were not in place and audit records for cleaning and infection control were not available. This meant the provider was unable to monitor the frequency and standard of cleaning and infection control. We also found that the provider had not undertaken the required recruitment checks with regard to a new member of staff.

We did not receive an action plan after the visit but the provider wrote to us immediately with attached documents, relating to improvements they had made in infection control and recruitment.

During this inspection we reviewed the progress the provider had made to meet essential standards in cleanliness and infection control and requirements relating to workers. We found that the provider now maintained the appropriate records relating to cleanliness and infection control and had initiated the appropriate recruitment checks for a member of staff. We saw cleaning schedules and an infection control audit were in place, and recruitment checks had been made for the member of staff identified during our inspection of 15 November 2013.

During our inspection, we spoke with three people who used the service, the Chair of the Patient Participation Group and five members of staff.

Overall people were satisfied with the service received. One person told us ‘I have no complaints’ and the practice is ‘well run’. Another person told us ‘I am satisfied and it is generally easy to get an appointment’.

People we spoke with told us that they were very happy with the doctors and the nurse. They all said that the doctors were very professional. One person told us that the practice nurse was ‘brilliant and very competent’.

We found that the service conducted appropriate assessments and ensured people were given an opportunity to make an informed choice about their care and treatment.

Staff we spoke with were aware of the signs of abuse and the action to take when responding to allegations or incidents of abuse. We observed that the provider had a safeguarding adults policy and a separate policy for safeguarding children.

We found that the premises did not meet government guidelines for the prevention of healthcare-associated infection.

We observed that appropriate checks had not been carried out for a recently employed member of staff.

We found that the provider had a system in place to monitor quality and safety.