Archived: Albion Street Surgery

Updated 27 September 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Albion Street Surgery on 17 December 2015. The practice was rated as requires improvement for safe and well led. The overall rating was requires improvement. Breaches of legal requirements were found.

Following on from the inspection the practice provided us with an action plan detailing the evidence of the actions they had taken to meet the legal requirements in relation to providing safe and well led services to the patients.  

We undertook a focused follow up inspection and visited the practice on 14 July 2016. This was to review in detail the information the practice had sent to us, observe the improvements made to the premises and to confirm that the practice were now meeting legal requirements. This report only covers our findings in relation to those legal requirements.

The full comprehensive report which followed the inspection in December 2015 can be found by selecting the 'all reports' link for Albion Street Surgery on our website at www.cqc.org.uk.

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

• Risks to patients were assessed and well managed. Risk assessments relating to health and safety, fire safety and COSHH (Control of Substances Hazardous to Health) had been undertaken. A fire alarm system, emergency lighting and exit signage had been installed. 
• The practice had a system to ensure patient safety alerts were received and acted upon. 
• Testing of the electrical hard wiring of the building had been undertaken and electrical fixtures had been replaced to meet modern standards.
• The practice manager and practice nurse were infection prevention and control leads. The practice had carried out IPC audits. Cleaning schedules had been introduced and were being followed.
• Clinical equipment was checked to ensure it was working properly.
• The practice carried out and documented actions such as flushing toilets and running taps in the disused bathroom which were necessary to prevent legionella contamination. Legionella is a term for a particular bacterium which can contaminate water systems in buildings.
• Staff had cleared the premises of inappropriate items and clutter had been removed.
• Practice specific policies were updated and were available to all staff.
• Effective arrangements had been made to identify, record and manage risks, issues and implement mitigating actions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice on our website at www.cqc.org.uk

Updated 27 September 2016

The provider had resolved the concerns identified for safety and well-led which applied to everyone using the practice, including this population group. T he population group ratings have been updated to reflect this.

Updated 27 September 2016

The provider had resolved the concerns identified for safety and well-led which applied to everyone using the practice, including this population group. T he population group ratings have been updated to reflect this.

Updated 27 September 2016

The provider had resolved the concerns identified for safety and well-led which applied to everyone using the practice, including this population group. The population group ratings have been updated to reflect this.

Updated 27 September 2016

The provider had resolved the concerns identified for safety and well-led which applied to everyone using the practice, including this population group. T he population group ratings have been updated to reflect this.

Updated 14 April 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

• The practice were addressing the number of patients inappropriately taking benzodiazipine medication and achieved a 16% reduction since 2014.
• GPs were following a template available on the clinical system to carry out dementia checks. However, only 67% of people diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months compared with the CCG average of 83% and the national average of 84%.
• The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations. For example MIND which offers specialised mental health support and care based on the needs of the community.
• It had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
• Staff had a good understanding of how to support people with mental health needs and dementia. The practice manager had undertaken additional mental capacity and Dementia Friends training which was to be discussed with other members of staff.

Updated 27 September 2016

The provider had resolved the concerns identified for safety and well-led which applied to everyone using the practice, including this population group. T he population group ratings have been updated to reflect this.