The Care Quality Commission
  • Doctor
  • GP practice

Oakside Surgery

Overall: Good read more about inspection ratings

Guy Miles Way, Honicknowle Green, Plymouth, Devon, PL5 3PY (01752) 766000

Provided and run by:
Oakside Surgery

All Inspections

23 March 2022

During an inspection looking at part of the service

We carried out an announced inspection at Oakside Surgery on 23 March 2022. The practice had previously been inspected in August 2021, when it was rated as Requires Improvement. This was because Safe, Effective and Well-Led domains did not meet the required standards. At the inspection in March 2022 we rated the service as Good.

Safe - Good

Effective - Good

Well-led – Requires improvement

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

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
  • Staff questionnaire’s

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 have rated this practice as Good overall.

We found that:

  • Improvements had been made to the areas previously identified as in need of improvement, however, not all of these were fully embedded.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff treated patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

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

  • Continue to work towards a single point of access system for Human Resource Management.
  • Have a formalised process to demonstrate how they assured the competence of staff employed in advanced clinical practice, for example, nurses and paramedics.
  • Continue to encourage the uptake of cervical screening and childhood immunisations.
  • Continue to work towards sucession planning to ensure the sustainability of the practice.

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

26 August 2021

During a routine inspection

We carried out an announced inspection at Oakside Surgery on 26 August 2021. Overall, the practice is rated as Requires Improvement.

Safe - Requires Improvement

Effective – Requires Improvement

Caring - Good

Responsive – Good

Well-led – Requires Improvement

Following our previous inspection on 12 May 2016, the practice was rated Good overall and Good for all key questions.

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

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
  • Staff Questionnaire’s

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 have rated this practice as Requires Improvement overall and requires improvement for all population groups.

We found that:

Safe

The service is now rated as requires improvement for providing safe services because :

  • The provider did not have clear safeguarding processes in place to keep patients safe. Not all staff were up to date with the appropriate level of safeguarding training for their role and safeguarding meetings were currently not being held.

  • Systems and processes relating to safety, including infection prevention and control and patient safety alerts, were not developed and implemented in a way that kept people safe.

  • The practice did not have a system to learn and make improvements when things went wrong.

  • Recruitment processes were not always safe.

  • Medicines requiring refrigeration were not being stored safely.

Effective

The service is now rated as requires improvement for providing effective services because:

  • Staff training was not effectively monitored and not all staff were up to date with mandatory training.

  • Not all staff had received annual appraisals.

  • Patient consent was not always recorded prior to receiving treatment.

Caring

The service is rated Good for providing caring services because :

  • Staff treated patients with kindness and respect and involved them in decisions about their care.

  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.

Responsive

The service is rated as Good for providing responsive services because:

  • The practice was not able to demonstrate they had responded to complaints appropriately.

However:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.

Well led

The service is now rated as requires improvement for providing well led services because :

  • The provider did not have effective governance arrangements in place to identify and mitigate risks to staff and patients.

.

We found three breaches of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way. (Please refer to the enforcement section at the end of the report for more detail.)

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. (Please refer to the enforcement section at the end of the report for more detail.)

  • Ensure staff receive the appropriate support, training, supervision and appraisal as necessary to enable them to carry out their duties. (Please refer to the enforcement section at the end of the report for more detail.)

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

24/03/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Oakside on 24 March 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • The practice had identified that data from the Quality and Outcomes Framework from 2014/15 showed patient outcomes were lower in four of the long term conditions. As a result they had been proactive in addressing the deficit by employing a nurse practitioner who had focused on improvements resulting in significant improvements. The result of this had seen a 16.5% increase in QOF score.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider should make improvements are :

  • Review the processes in place to develop the patient participation group.

  • Ensure all information available for patients regarding contacting the out of hours service is up to date.

  • Ensure the area surrounding the fire door is accessible for patients whose mobility is poor, should an emergency building evacuation be required.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

2 June 2014

During an inspection looking at part of the service

The practice was inspected by the Care Quality Commission in October 2013. We found that improvements were required with regard to safeguarding people. None of the staff knew the correct local safeguarding procedures; although all were confident they would find out and take appropriate action. Staff had attended safeguarding children training but not all had attended safeguarding adult training. The policies for safeguarding adults and children contained incorrect contact numbers. Therefore staff at the surgery lacked sufficient knowledge to ensure people would be referred to statutory agencies in time of need and receive appropriate support.

Following the inspection the provider wrote to us and, in a detailed action plan, described the arrangements that would be put in to place to achieve compliance. We visited the practice on the 3 June 2015 and we found that the provider had made all the necessary improvements to become compliant within these areas.

2 October 2013

During a routine inspection

We spoke with eight patients who were pleased with the service they received from the practice. Patients told us they had been involved in the decisions made about their care. Patients said care was "without question very good" and "excellent". We spoke with two parents who were both "pleased" with the care their families received.

We were told that staff treated people with respect and dignity. Facilities were available for people with disabilities and translation services were available for people whose first language was not English.

None of the staff knew the correct local safeguarding procedures although all were confident they would find out and take appropriate action. Staff had attended safeguarding children training but not all had attended safeguarding adult training. The policies for safeguarding adults and children contained incorrect contact numbers.

Patients told us that they always felt safe in the care of the staff. There were appropriate arrangements in place which ensured that staff kept their knowledge and skills up to date. Staff spoke about the supportive environment and confirmed that they had access to adequate training.

The practice was organised and well led. There were effective systems in place to monitor the quality of the service provided and patients felt able to give feedback about the service they received.