Salisbury Avenue Healthcare

We carried out an announced comprehensive site inspection at Salisbury Avenue Healthcare on 1 December 2022. This was accompanied by a remote inspection on 15 December 2022, 22 December 2022 and 9 January 2023. Overall, the practice is rated as inadequate.

Safe - inadequate

Effective - inadequate

Caring - requires improvement

Responsive - inadequate

Well-led - inadequate

Following our previous inspection on 15 January 2016 and a subsequent follow up inspection of 6 September 2016 and a focused inspection on 29 May 2019, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Salisbury Avenue Healthcare 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. Further concerns were raised following the 1 December 2022 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 and telephone 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 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 did not have adequate systems, practices and processes to keep people safe and safeguarded from abuse.
• The systems to assess, monitor and manage risks to patient safety were inadequate.
• Staff did not always have the information they needed to deliver safe care and treatment.
• The practice did not have systems for the appropriate and safe use of medicines.
• The practice did not have an adequate system to learn and make improvements when things went wrong.
• The practice had not taken steps to improve in all the areas of lower than average performance identified in the national GP patient survey.
• The practice could not demonstrate how they complied with the accessible information standard.
• Patients were not always involved in decisions about care and treatment.
• The practice was unable to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
• Patients’ needs were not always assessed, and care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance.
• Complaints were not always used to improve the quality of care.
• Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care.
• The overall governance arrangements were inadequate.
• The practice culture did not adequately support high quality sustainable care.

We found breaches of regulations. The provider must:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

• Implement a system to improve the identification of and support of carers and young carers in the practice.
• Consider implementing a language translate option on the practice website.
• Review and improve cervical screening uptake.
• Review and improve childhood immunisations.
• Take action to respond to areas of low patient satisfaction.
• Consider patient satisfaction surveys.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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