Letter from the Chief Inspector of General Practice

This is the report from our inspection of Toft Road Surgery. Toft Road Surgery is registered with the Care Quality Commission to provide primary care services.

We undertook a planned, comprehensive inspection on the 2 December 2014 at Toft Road Surgery. We reviewed information we held about the services and spoke with patients, GPs, and staff.

The practice was rated as Good overall.

Our key findings were as follows:

• There were systems in place to mitigate safety risks. The premises were clean and tidy. Systems were in place to ensure medication including vaccines were appropriately stored and in date.

• Patients had their needs assessed in line with current guidance and the practice promoted health education to empower patients to live healthier lives.

• Feedback from patients and observations throughout our inspection highlighted the staff were kind, caring and helpful.

• The practice was responsive and acted on patient complaints and feedback.

• The practice was well led. The staff worked well together as a team and had regular staff meetings and training.

However,

The provider should:

• Ensure a system is in place for checking how many prescription pads were available on the premises and tracking when they were used so they could be accounted for.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Toft Road Surgery on 7 March 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.

The overall rating for this practice was requires improvement due to concerns in providing safe and well-led services. However, the population groups were rated as good because patients were able to access timely and effective care and treatment.

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

• The systems for the management of medicines were not robust.
• The systems for managing significant events did not demonstrate that robust investigations took place and the actions and learning from incidents were effectively shared, reviewed and documented.
• The systems and processes in place to monitor and act on safeguarding concerns was not robust.

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

• The overall governance arrangements in place were limited and did not support an overview of the performance of the service.
• The practice had not undertaken risk assessments with regard to the premises.

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

• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The area 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.
• Ensure the safeguarding process, systems and practice protects patients from abuse.

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

The areas where the provider should make improvements are:

• Introduce a system for the regular cleaning of carpeted areas and ensure toys in consultation rooms are cleaned regularly.
• Introduce a system to check infection control standards are being maintained in between annual audits, to record spot checks of the cleaning undertaken by the cleaners and to record when equipment such as nebulisers are cleaned.
• Introduce a system to audit patient consent to check this is being appropriately sought and recorded.
• Introduce a comprehensive programme of quality improvement and use this information about care and treatment to make improvements.
• Ensure that patient records reflect all engagements that discuss their care and treatment.

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

Dr Rosie Benneyworth

BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

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