We carried out an announced comprehensive at Heaton Road Surgery on 23 and 27 September 2022. Overall, the practice is rated as good.
Safe - requires improvement
Effective - good
Caring - good
Responsive - good
Well-led - good
Following our previous inspection on 10 February 2015 the practice was rated outstanding overall.
At the last inspection we rated the practice as outstanding for providing caring, responsive and well-led services because:
- They had implemented targeted support for those patients who were high-risk, such as those who required palliative care, the house bound and care home patients.
- They had identified and implemented improvement plans following poor staff satisfaction levels.
At this inspection, we found that those areas previously regarded as outstanding practice were now embedded throughout the majority of GP practices. While the provider had maintained this good practice, the threshold to achieve an outstanding rating had not been reached. The practice is therefore now rated good for providing caring, responsive and well-led services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Heaton Road Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection in line with our inspection priorities.
- This was a comprehensive inspection which considered whether the practice was safe, effective, caring, responsive and well-led.
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.
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 found that:
- The practice mostly 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 dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients could access care and treatment in a timely way.
- The way the practice was led promoted the delivery of high-quality, person-centre care. Leaders had a clear strategic vision for the practice and understood the challenges they faced, but this wasn’t always translated into the business planning process.
We rated the practice as requires improvement for providing safe services because:
- The practice had not followed UK Health and Security Agency guidance on safe storage of medicines and maintaining records of staff immunisations.
- The practice had not maintained an appropriate audit trail of significant events to support the practice to learn and improve.
- There were a small percentage of patients prescribed high-risk medicines where monitoring had not been carried out in line with best practice guidance.
Whilst we found no breaches of regulations, the provider should:
- Maintain a full record of staff vaccination status in line with current UK Health Security Agency guidance.
- Continue with the changes implemented following the CQC site visit to safely and effectively handle samples from patients.
- Continue with plans to follow up the small percentage of patients prescribed high-risk medicines or with long term conditions who do not respond to review appointment invites or are hard to reach, to ensure these patients receive safe care and treatment.
- Encourage proactive and collaborative discussions to support and protect adults and children at risk of significant harm by holding regular multidisciplinary meetings.
- Improve the business planning and governance processes to ensure they support the practice to meet their aspirations whilst supporting effective documentation to be maintained.
- Improve the uptake of cervical screening and childhood immunisations to support patients to maintain good health.
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 Hospitals and Interim Chief Inspector of Primary Medical Services