Canvey Village Surgery

We carried out an announced comprehensive inspection at Canvey Village Surgery on 22 November 2023. Overall, the practice is rated as requires improvement.

Safe – requires improvement

Effective – requires improvement

Caring - good

Responsive – requires improvement

Well-led – requires improvement

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A site visit.
• Conducting staff interviews via video conferencing and face to face.
• Staff questionnaires

Our findings

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 found that:

• Some patients’ care needs were not always reviewed and monitored in line with current legislation and standards.
• Safety alerts were not consistently discussed with patients as recommended.
  Staff had received appropriate training and there were effective health and safety risk assessments.
• Some patients with long term conditions were not always reviewed in line with current legislation and standards to ensure they received the appropriate care.
• Cervical screening uptake was below national target.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice performance for the access indicators in the national GP survey for 2020, 2021 and 2022 was below the local and national average and this had further declined in 2023. Although some action to improve access was ongoing, this was yet to be reflected in improved patient feedback.
• There were a range of governance issues that required improvement around the management and oversight of people receiving treatment for some high-risk medicines and long-term conditions.
• There was no programme of clinical or non-clinical audits to improve patient care.
• Staff had received appropriate training and there were effective health and safety risk assessments.
• Staff spoke positively about leaders and felt supported.
• The practice had achieved 100% take up for 3 of the 5 Child Immunisation indicators.

We found 1 breach of regulations. The provider must:

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

We also found that the provider should:

• Continue with efforts to seek and act on patient feedback and embed learning to improve the patient experience.
• Continue with efforts to complete the recording of staff vaccinations.
• Continue to monitor and improve cervical screening rates.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care