Ambrose Avenue Group Practice

Updated 21 March 2024

Ambrose Avenue Group Practice has 2 locations in Colchester at:

Tollgate Health Centre

145 London Road

Stanway

Colchester

Essex

CO3 8NZ

Where the open access appointments are held.

76 Ambrose Avenue

Colchester

CO3 4LN

Where long term condition management appointments are held.

We did not visit the Ambrose Avenue site as part of this inspection.

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

The practice is situated within the Suffolk and North East Essex Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of about 15,280. This is part of a contract held with NHS England.

The practice is part of a wider primary care network (PCN) of GP practices.

There is a team of 4 GP partners, and 5 salaried GPs who provide clinical cover at the practice. The practice has a team of 2 nurse practitioners, 2 nurses, 2 healthcare assistants and a phlebotomist who provide nurse led care and treatment. The GPs are supported at the practice by a team of reception/administration staff. A practice manager, finance manager, a facilities manager and reception manager provide managerial oversight.

The practice is open between 8am to 6.30pm Monday to Friday. The practice offers a range of appointment types including open access on the day, pre-bookable, online and telephone consultations.

Extended access is provided locally by the PCN, where late evening and weekend appointments are available. Out of hours services are provided by the 111 service.

Updated 21 March 2024

We carried out an announced comprehensive inspection at Ambrose Avenue Group Practice on 12th December 2023. Overall, the practice is rated as Requires Improvement.

Safe - Good

Effective - Good

Caring – Requires Improvement

Responsive – Requires Improvement

Well-led – Requires Improvement

Following our previous comprehensive inspection on 16 February 2016, the practice was rated Good overall and for all key questions. We had also carried out an inspection on 8 December 2021 in response to data that had identified possible risk in terms of access, this was focussed on the management of access to appointments and was not rated.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Ambrose Avenue Group Practice on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection to follow up on concerns received from patients which included access to the practice, and the impact on service quality due to the high turnover of staff. These concerns were shared with the Integrated Commissioning Board (ICB).

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:

• Conducting staff interviews using video conferencing.
• 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 short site visit.
• 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.
• Staff feedback surveys.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• There were appropriate infection control procedures in place, that were regularly monitored for assurance.
• Staff recruitment procedures were appropriate, and training, competencies, and immunisation status were recorded.
• 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. However, patient experience had declined over the last 3 years in regard to patients overall experience at the practice.
• There was a high turnover of staff leading to a lack of consistency and confidence in staff.
• Patients could not access care and treatment in a timely way.
• The way the practice was led and managed did not promote the delivery of person-centre care.

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 the newly implemented system to monitor the temperature of the room where emergency medicines are stored.
• Continue to work with new staff to bring work force to full strength, training, and effectiveness.
• Continue to monitor and reduce quantity of hypnotics and multiple psychotropic prescribing.
• Continue to improve patient experience and access for patients to appointments.
• Document learning from incidents and complaints and share learning and actions with staff.

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