We carried out an announced review at Abbey Road Medical Practice on 20 April 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led – Good
Following our previous inspection on 18 November 2019, the practice was rated Good overall and for the key questions effective, caring, responsive and well-led. The practice was rated requires improvement for providing safe services and issued a requirement notice for Regulation 12 Safe care and treatment and Regulation 17 Good governance.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Abbey Road Medical Practice on our website at www.cqc.org.uk
Why we carried out this review
This review was a focused review of information without undertaking a site visit to follow up on breaches of Regulation 12 Safe care and treatment and Regulation 17 Good governance. At the previous inspection we found:
- Most systems, practices and processes to keep people safe and safeguarded from abuse were in place, but some had gaps including health and safety and staff checks.
- The way the practice was led and managed generally promoted the delivery of high- quality, person-centre care. Some areas of governance and risk management needed reviewing which was underway.
We also followed up on areas we identified the practice should improve at the last inspection. Specifically:
- Review and embed arrangements to ensure improved performance for clinical cancer care indicators.
- Review and improve arrangements to ensure formalised clinical oversight for practice nurse prescribers and pharmacists.
How we carried out the review
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 reviews differently.
This review was carried out without visiting the location by requesting documentary evidence from the provider.
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 and for all population groups.
The practice had made the necessary improvements to the delivery of care to ensure patients were kept safe and protected from avoidable harm:
- The practice had improved and remedied safety concerns including fire safety, Control of Substances Hazardous to Health (COSHH), and premises safety including boiler and fixed wiring.
- Arrangements were in place to ensure effective systems for staff HR checks including DBS, staff occupational and health immunity status, and clinician’s registration with the appropriate body checks.
- There was oversight of role specific and mandatory staff training, including to ensure fire marshals cover across the rota.
- Published data cancer care performance indicators had improved since our previous inspection including urgent referrals detection rate and screening for breast, bowel and cervical cancer.
- The practice implemented arrangements to assure itself of sufficiently comprehensive, effective and sustainable systems and processes. For example, the practice engaged input from external consultants where appropriate and reviewed processes for risk management including health and safety, HR procedures reviews, and relating to Infection Protection and Control during the pandemic.
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.
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