We carried out a review of the data available to us about The Avenues Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about The Avenues Medical Centre, you can give feedback on this service.
We carried out an announced comprehensive inspection of this practice on 20 October 2015. A breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to;
Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – safe care and treatment.
Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – good governance.
Regulation 19 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – fit and proper persons employed.
We undertook this focused inspection on 9 June 2016, to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting 'all reports' link for The Avenues Medical Centre on our website at www.cqc.org.uk
From the inspection on 20 October 2015, the practice were told they must:
Improve recruitment arrangements and all necessary employment checks for all staff.
Complete risk assessments for the full environment. Additionally, blinds on the windows and the blind loop cords were safe and secured as these could potentially be a choking hazard to small children when attending the surgery. Refer to Estates and Facilities Alert (EFA/2015/001 issued 26 January 2015).
Implement a system of reporting incidents without fear of recrimination and monitor learning from outcomes of analysis, patterns and trends of incidents.
Monitor the prevention and control of infection.
Complete health and safety risk assessments on the environment to reduce the risk of harm to patients.
Ensure systems are in place for identifying and monitor the completion of training for all staff in order for them to carry out their duties effectively and safely.
We found that on the 9 June 2016 the practice now had improved systems in place.
Records we looked at confirmed that staff recruitment checks had been completed.
We saw that health and safety risk assessments had been completed on the practice premises and environment including for patients with limited mobility and assessment adjustments to the blinds.
The practice policy and procedures had been updated to include a mechanism for all staff to record incidents and concerns without fear of recrimination and staff we spoke to were clear about their duties in relation to this.
We saw that the practice had completed hand washing audits and cleanliness checks. Additionally, a recent infection control audit had been commissioned and action points identified. Some of the action points were completed and some were in the process of completion.
Records we looked at confirmed training for all staff had been updated and a responsible lead member of staff was allocated the duty to monitor training progress.
We saw records that defined key leaderships roles in the practice and staff we spoke with understood their roles.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at The Avenues Medical Centre on 20 October 2015.
Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, health and safety risk assessments had not been completed on the environment.
Actions identified to address concerns with infection control arrangements had not been taken.
Information about services and how to complain was available and easy to understand.
The areas where the provider must make improvements are:
Recruitment arrangements must include all necessary employment checks for all staff.
Risk assessments must be completed for the full environment. Additionally, blinds on the windows and the blind loop cords were long and could potentially be a choking hazard to small children when attending the surgery. Refer to Estates and Facilities Alert (EFA/2015/001 issued 26 January 2015).
A system of reporting incidents without fear of recrimination and whereby learning from outcomes of analysis, patterns and trends of incidents was not fully implemented.
There must be mechanisms in place to manage and monitor the prevention and control of infection.
In addition the provider should:
Systems must be in place for identifying and monitor the completion of training for all staff in order for them to carry out their duties effectively and safely.
Two GPs we spoke with told us the practice did not have a carers register in place but was something planned for the future.
Chief Inspector of General Practice