Care watchdog says Toft Road surgery 'requires improvement'

The CQC carried out an announced inspection at the practice on March 7.

The overall rating from the CQC was that the practice required improvement due to concerns in providing safe and well-led services.

Dr Rosie Benneyworth, Chief Inspector of Primary Medical Services and Integrated Care, said in her report: “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 were not robust. We rated the practice as requires improvement for providing well-led services because the overall governance arrangements 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 it reviewed the effectiveness and appropriateness of the care it provided.

“It ensured 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 report said the practice must make improvements to ensure care and treatment is provided in a safe way; to establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care; and ensure the safeguarding process, systems and practice protects patients from abuse.

It added that the practice should make improvements by introducing a system for regular cleaning of carpeted areas and ensuring toys in consultation rooms are cleaned regularly; introducing 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; introducing a system to audit patient consent to check this is being appropriately sought and recorded; introducing a comprehensive programme of quality improvement and use this information about care and treatment to make improvements; and ensuring patient records reflect all engagements that discuss their care and treatment.

Acting Senior Partner Dr David Hans said: “We are proud the CQC rated all aspects of our patient care as ‘good’. Nevertheless, we have wasted no time in implementing their recommendations for improvement.

“Our staff are already receiving extra training, both online and changes to protocol, to ensure our medicines management is as safe as it can possibly be.

“We have introduced and are already using a new significant event protocol to robustly ensure maximum learning takes place for the whole team.

“Safeguarding is and always will be our priority for both children and adults, and as such we have thoroughly reviewed our policy.

“We’ve appointed a specialist company to overhaul our risk assessment process, which is extremely difficult to do well, whilst working in premises we would dearly love to be updated.

“We will continue to hold our patient care as our top priority, we appreciate that this CQC report has highlighted the administrative areas that could be improved."