The Care Quality Commission
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Archived: Ambrose Avenue Group Practice

Overall: Requires improvement read more about inspection ratings

76 Ambrose Avenue, Colchester, Essex, CO3 4LN (01206) 549444

Provided and run by:
Ambrose Avenue Group Practice

Important: The provider of this service changed. See new profile

All Inspections

12 December 2023

During a routine inspection

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

16 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Ambrose Avenue Group Practice on 16 February 2016. Overall the practice is rated as good.

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

  • Patients were protected from abuse and avoidable harm as staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.

  • Risks to patients were assessed and well managed. Information about safety was monitored, appropriately reviewed and addressed. Learning from incidents was cascaded to staff.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. There were multi-disciplinary team discussions to ensure patients’ care and treatment was coordinated.
  • Patients said they were treated with compassion and dignity 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 could make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The premises were purpose built and maintained to an acceptable standard throughout the clinical areas. Access for disabled people was in place including parking for the disabled and washroom facilities.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.
  • There was a leadership structure and staff had lead roles in the delivery of services.Staff were appropriately qualified and competent to carry out their roles safely and effectively in line with best practice. Staff were supported and received satisfactory supervision and appraisal and were encouraged to undertake their continual professional development.

The areas where the provider should make improvement are:

  • The practice should have a clear vision and strategy to deliver ongoing high quality care and promote good outcomes for patients. Staff should be clear about the vision and their responsibilities in relation to this.

  • There should be a formal policy and arrangements in place to ensure that MHRA medicine alerts are always actioned in a timely manner.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

28 November 2013

During a routine inspection

We inspected Ambrose Group Practice on 28 November 2013. We found the practice staff in the reception area to be courteous and welcoming.

There was a varied selection of information on the notice boards and in the waiting room for the benefit of the patients. The information included notices about the practice, health promotion, safeguarding and other support services.

We received comments from ten people who visited the practice on the day of inspection. One person told us: "The doctor made me aware of treatment options, I'm very happy with the service."

We saw that staff spoke politely to people and consultations were carried out in private treatment rooms.

The doctors and nurses told us how they involved people in their care. We saw the surgery had appropriate medicines management arrangements in place.

We spoke with four members of staff about the support they received and saw records of appraisals, regular training, staff meetings, and staff development.

We were shown the audits completed by the practice which monitored the quality of service people received.