We carried out an announced comprehensive inspection at the location on 12 April 2018 when the overall rating for the practice was Good with Requires Improvement for providing well-led services because the provider was failing to ensure systems and processes were operated effectively to improve the quality and safety of services. In particular:

• The provider had failed to address risk assessment outcomes in a timely manner.
• The provider had failed to ensure patient risk registers were up-to-date.
• There was no written business plan and strategy in line with health and social priorities to meet the needs of its practice population.

The full comprehensive report on the 12 April 2018 inspection can be found by selecting the ‘all reports’ link for Uxendon Crescent Surgery on our website at www.cqc.org.uk.

This inspection, on 28 March 2019, was an announced comprehensive inspection to confirm that the practice had carried out their plan to meet the requirements that we identified in our previous inspection on 12 April 2018. At this inspection, we found that the provider had satisfactorily addressed these areas.

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 good overall and good for all population groups.

We found that:

• The practice had been proactive and addressed all the findings of our previous inspection.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• 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 way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

• Continue to work towards all staff attaining safeguarding children training to a level recommended in updated guidance.
• Consider providing enhanced infection prevention and control training for the lead to support them in the role.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Uxendon Crescent Surgery on 6 June 2017. The overall rating for the practice was Requires Improvement. The full comprehensive report on the 6 June 2017 inspection can be found by selecting the ‘all reports’ link for Uxendon Crescent Surgery on our website at www.cqc.org.uk.

This inspection, on 12 April 2018, was an announced comprehensive inspection to confirm that the practice had carried out their plan to meet the requirements that we identified in our previous inspection on 6 June 2017. This report covers our findings in relation to those requirements and any improvements made since our last inspection. The practice is now rated as Good overall.

The key questions 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

At this inspection we found:

• The practice had addressed the findings of our previous inspection in respect of infection prevention and control, practice cleanliness, risk assessments, systems to check emergency medical equipment, the management of two-week wait referrals, repeat prescribing, prescription stationery management and significant events.
• The practice had systems and processes in place to support good governance. However, we found that these were inconsistent.
• The practice had not produced a supporting written strategy or business plan to support the provision of high quality care and good patient outcomes, which had been a finding of our previous inspection.
• There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns. However, some patient risk registers were not kept up-to-date and did not include all vulnerable groups.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events. 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 had systems in place to ensure care and treatment was delivered according to evidence-based guidelines.
• Results from the national GP patient survey showed patients rated the practice comparable with others for aspects of caring. Patients told us they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients were able to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Consider undertaking audits to monitor the prescribing of controlled drugs and review the arrangements for raising concerns around controlled drugs with the NHS England Area Team CD Accountable Officer.
• Review the reception staff understanding of ‘red flag’ sepsis symptoms that might be reported by patients and how to respond.
• Review the process for disseminating new clinical guidance to all clinicians.
• Review the Core Standards for Pain Management Services in the UK regarding the current practice recommendations and assessment tools for pain management in primary care.

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 Uxendon Crescent Surgery on 15 February 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 15 February 2016 inspection can be found by selecting the ‘all reports’ link for Uxendon Crescent Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 6 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 15 February 2016. This report covers our findings in relation to those requirements and any improvements made since our last inspection.

Overall the practice remains rated as requires improvement.

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

• Although the practice had made some improvements since our previous inspection we found it had failed to act upon all of the findings and only addressed some outstanding issues on the day of the inspection or immediately after the inspection in response to feedback.
• There was a system for reporting and recording significant events and staff were aware of the significant event reporting process. However, there was limited use of the system, the policy was out-of-date and it was unclear how learning was effectively implemented and change and trends monitored.
• Staff demonstrated that they understood their responsibilities and all had received training on safeguarding children and vulnerable adults relevant to their role.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available but patient complaint correspondence did not contain patient information in line with guidance.
• Patients spoke highly about the continuity of care provided by the GPs which they told us was attributable to the named doctor system operated by the practice.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvement 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.

The areas where the provider should make improvement are:

• Ensure all actions identified in the Infection Prevention and Control (IPC) audit are acted upon.
• Review the management of the cold chain to ensure it is in line with best practice.
• Display the mission statement so it is visible within the practice.
• Consider implementing a consistent practice meeting structure.

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 Uxendon Crescent Surgery on 15 February 2016. Overall the practice is rated as requires improvement.

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.
• Some risks to patients were assessed and well managed, with the exception of those relating to safeguarding, chaperoning, infection control, fire safety, dealing with emergencies, emergency medicines and recruitment checks.
• We saw three completed clinical audits driving improvement, these were all CCG led audits.
• Staff had the skills, knowledge and experience to deliver effective care and treatment however, they were unable to reference current evidence based guidelines.
• Results were not actioned in a timely manner on the computer system and there was a poor audit trail of results actioned on paper.
• Patients with complex long term conditions and at risk of admission were provided with Whole Systems Integrated Care (WSIC) care plans and were also supported by the Complex Patient Management Group (CPMG) consisting of a core team of health and social care professionals resulting in patient outcomes that were higher than local and national average.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patient information was available in different languages and information about services and how to complain was available and easy to understand.
• 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 practice had a number of policies and procedures to govern activity, but some were overdue a review and staff were not aware of some of them.
• Staff were not aware of the Duty of Candour or whistleblowing policy.
• The practice was proactive in taking part in pilot schemes which focused on improving patient experience of the service.

The areas where the provider must make improvements are:

• Ensure governance processes are in place to monitor safety, and fire safety risk.

• Ensure effective systems and processes to safeguard adult and children from abuse are established and operated effectively.

• Ensure recruitment arrangements include all necessary pre-employment checks for all staff including Disclosure and Barring Service (DBS) checks.

• Ensure sufficient medicines are available in case of emergencies.

• Ensure accurate records of all decisions taken in relation to care and treatment are accurate and make reference to discussions with patients and their carers. This includes consent records, medical reviews and chaperoning records.

• Ensure clinical staff are aware of relevant nationally recognised guidance.

• Review and update policies and procedures, and ensure all staff are aware of these.

In addition the provider should:

• Ensure referrals are actioned in a timely manner and good record keeping is maintained in relation to filing reports on the computer system.
• Review the frequency of staff meetings and consider keeping a record of the discussions to ensure all staff are aware of decisions or changes in the practice.
• Advertise translation services within the practice to make patients aware of this service.
• Ensure staff knowledge of the Duty of candour or whistleblowing policy.

• Display the mission statement so it is visible within the practice.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Five patients we spoke with informed us that they had been treated with respect and dignity by their GPs and other staff working in the practice. They were satisfied with the services provided. One patient told us, "This is one of the best practices around”. Another patient said, “The doctors and staff are understanding of my culture and problems. They show respect for me. However, sometimes it is difficult to get an appointment”. A third patient said, “The staff are professional. The quality of the service is good”.

Records of patients contained details of assessments and their past medical history. Treatment and care were documented and where necessary, consent had been obtained. Reviews of treatment took place and there was a system for following up patients who had missed important appointments. There was documented evidence that the GPs and practice nurse had updated their professional knowledge.

Patients expressed confidence in the GPs and other staff. Staff were aware of their roles and responsibilities. The staff records contained essential checks carried out on staff. These included criminal record checks, evidence of identity and references. There were arrangements for new staff to be provided with a period of induction.

The practice had a policy and procedure for safeguarding people from abuse. Staff were aware of action to take when responding to allegations or incidents of abuse.

The practice had a system to regularly assess and monitor the quality of service that patients received. Issues affecting the care of patients and the running of the practice had been discussed in Patient Participation Group (PPG) meetings. Complaints made had been recorded and responded to. The practice had a record of compliments received.