Archived: Dr Michael Cavendish Also known as The Hodford Road Surgery

We carried out an announced comprehensive inspection at Dr Michael Cavendish (Hodford Road Surgery) on 14 November 2019. We decided to undertake an inspection of this service following our annual review of the information available to us.

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 have rated this practice as requires improvement overall. The key questions were rated inadequate for safe, requires improvement for effective and well-led and good for caring and responsive. Two of the six population groups were rated as requires improvement, the remaining four population groups were rated as good .

At this inspection we identified a breach of regulations 12 (safe care and treatment). We will carry out a focussed follow-up inspection within the next six months to ensure the practice is compliant with the regulations where breaches have been identified.

We rated the practice as inadequate for providing safe services because:

• Patient safety was put at risk because prescribing of high-risk medicines was not always in line with national guidance.

We rated the practice as requires improvement for providing effective services because:

• The system for managing staff training was not always effective and not all staff had completed annual mandatory training.
• The practice was performing above local and national averages for several clinical indicators. However, there was no clear plan in place to improve the poor uptake for childhood immunisations and cervical screening.

We rated the practice as requires improvement for providing well-led services because:

• There was a reasonable system of governance however some areas required improvement to ensure risks were identified and acted upon.

These areas affected two population groups, families children and young people and working age people (including those recently retired and students). These two population groups have been rated as requires improvement.

The remaining four population groups have been rated as good as detailed in the evidence table under the responsive and effective key questions.

We rated the practice as good for providing caring and responsive services because:

• Staff treated patients with dignity and respect.
• Patient feedback was positive about the service.
• The practice took account of the needs of its patients and made the service accessible.

The areas where the provider must make improvements are:

• Ensure national guidance is adhered to for the management of all high-risk medicines.

The areas where the provider should make improvements are:

• Ensure the systems used to manage staff training are effective and identify gaps in training requirements.

• Ensure there is a failsafe system in place for patients given two week wait referrals.
• Review current nursing provision at the practice with a view to improving clinical outcomes for patients.
• Ensure vaccine fridge temperature logs include minimum and maximum temperatures.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care