Southend Road Surgery

Updated 12 June 2023

271a Southend Road is located in Stanford Le Hope at:

271A Southend Road,

Stanford Le Hope,

Essex,

SS17 8HD

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Mid and South Essex Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of about 2,907. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices which form Stanford Le Hope Primary Care Network (PCN).

Information published by Public Health England shows that deprivation within the practice population group is in the seventh lowest decile (seven of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 92.2% White, 2% Black, 1.3% Asian, 1.2% Mixed, and 0.3% Other.

There is a team of two GPs who provide cover at the practice. The practice has a practice nurse who provides nurse led clinics for long-term conditions. The GPs are supported at the practice by a team of reception/administration staff. A practice manager provides managerial oversight.

The practice is open between 8.30am to 6.30pm Tuesdays to Thursday, 8.30am to 8pm Mondays and Fridays. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally by the Primary Care Network. Out of hours services are provided by IC24 via 111.

Updated 12 June 2023

We carried out an announced focused inspection at 271a Southend Road on 31 May 2023. Overall, the practice is rated as Good.

Safe - Good

Effective – Good

Responsive – Good

Well-led - Good

Following our previous inspection in August 2022, the practice was rated requires improvement overall. The practice was rated inadequate for providing safe services, requires improvement for providing effective and well – led services and good for providing caring and responsive services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for 271a Southend Road on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection to follow up on concerns from our previous inspection in August 2022.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider
• A short site visit.

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.

In August 2022, we rated the practice Requires Improvement overall.

We previously found that:

• There were systems in place for the safeguarding of vulnerable adults and children, however not all staff had received safeguarding training appropriate to their role.
• There was a lack of risk assessments in place to identify and take action to mitigate risks.
• There was a lack of assurance that patients received appropriate monitoring of their medication and medical condition.
• Patients did not always receive care and treatment in line with guidelines.
• The practice had not met the 90% minimum target for childhood immunisation uptake for children aged five, however the practice had met the 95% WHO based target for childhood immunisations for children aged one and two.
• There was a lack of assurance that staff had received relevant training at an appropriate level to perform their role.
• Large parts of the governance structure were reliant on one member of staff, other staff found it difficult to access information in their absence.
• There were gaps in the effectiveness of governance arrangements which impacted on the safety of patients and staff.

In May 2023, we rated the practice Good overall.

We found that:

• There were processes in place for the safeguarding of vulnerable adults and children, all staff had received safeguarding training appropriate to their role.
• There was a number of environmental risk assessments in place. Concerns identified has been actioned to mitigate risks.
• The practice had improved and embedded their monitoring systems for patients being prescribed medication. We found the practice had taken action to review patients in line with national guidance. The practice continued to improve the system to code medical conditions on patients records to ensure all patients received the relevant monitoring. We were assured that the systems in place kept patients safe.
• The practice had continued to encourage patients to attend childhood immunisations.
• We found that all staff had completed annual appraisals.
• The practice had systems in place to monitor that staff had received appropriate training to perform their role.
• The practice had implemented processes to ensure that information was accessible to all leaders.
• Governance arrangements had been reviewed to ensure the safety of patients and staff.
• The practice had a system in place to deal with patient safety alerts.
• Staff found leaders approachable and felt the practice worked together as a team.

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

• Continue to improve the uptake childhood immunisations and national cancer screening.
• Strengthen systems to ensure patient records are coded correctly.
• Continue to carry out appraisals for all staff members.
• Increase engagement of the patient participation group.

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