The Care Quality Commission
  • Doctor
  • GP practice

Park Surgery

Overall: Requires improvement read more about inspection ratings

The Park Surgery, Albion Way, Horsham, West Sussex, RH12 1BG (01403) 330266

Provided and run by:
Park Surgery

All Inspections

19 May 2022

During an inspection looking at part of the service

We carried out an announced inspection at Park Surgery between 17 May 2022 and 20 May 2022. Overall, the practice is rated as Requires Improvement.

The key questions are rated as:

Safe - Requires Improvement

Effective - Good

Responsive – inspected but not rated

Well-led – Requires Improvement

At our previous inspection in 2017 the practice was rated as good overall and good for providing safe, effective, caring, responsive and well-led services. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Park Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on information of concern.

How we carried out the inspection

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 inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • 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 have rated this practice as Requires Improvement overall

We found that:

  • The practice, in most instances, 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.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The practice had implemented plans to address the results of feedback from staff and patient surveys.

We rated the practice as requires improvement for providing safe services because:

  • The monitoring and prescribing of patients’ medicines, including those that were high risk, did not always demonstrate that patients had all the required healthcare monitoring.
  • Action plans for health and safety, fire and legionella risks assessments, were not in place in the practice.

We rated the practice as requires improvement for providing well-led services because:

  • Leaders had demonstrated that they had a credible strategy to develop sustainable care.
  • However, at this inspection we identified concerns around clinical governance.
  • Health and safety risk assessments were not always accurate and managed in a way that provided appropriate reassurances that actions had been taken.

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.

The provider should:

  • Keep under review and act where necessary, to respond to patient feedback and experience on access to services.
  • Continue to support the patient participation group (PPG) with patient engagement.
  • Continue to build on the practice action plans, including staff engagement and communication strategies.
  • Keep staffing levels under review.
  • Continue and keep under review, the staff vaccination action plan in line with current UK Health and Security Agency (UKHSA) guidance, relevant to their role.
  • Continue to monitor the uptake of cervical screening.

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

11 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Park Surgery on 11 January 2017. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were generally treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they had experienced some difficulties making appointments in advance although urgent appointments were available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The practice had a strong emphasis on continuous improvements with evidence of proactive quality improvement and the use of clinical audit, was a training practice and actively participated in research.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
  • The practice had three defibrillators inside the building and one outside that could be used by the public.

We saw one area of outstanding practice:

  • A member of staff acted as a carers’ champion to help ensure that the various services supporting carers were coordinated and effective. Carer support groups were held regularly at the practice. The practice care coordinator role was in place to support both carers and patients who required additional support. The practice evaluated the service provided and collated feedback and 87% of 23 survey respondents reported they felt more independent in their own home as direct result of the contact they had with the care coordinator.

The areas where the provider should make improvement are:

  • Continue to take action to improve patient access to appointments and the phone lines and monitor through the use of repeat patient surveys and a review of satisfaction.
  • Review patient satisfaction with consultations in relation to the GP patient survey e.g. in relation to nurses explaining tests and treatments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

15 August 2013

During a routine inspection

We spoke with five patients who used the service who had attended on the day of inspection for an appointment. These patients were randomly selected. The receptionists handed out slips to patients asking them if they would be prepared to speak with us either in person or on the telephone.

We spoke with staff that included; the practice manager, a practice nurse, a healthcare assistant, two receptionists and the registered manager, who was the lead general practitioner (GP). We also spoke with the health visitor and midwife who although not employed by the surgery offer a service to patients. We spoke with the chairman of the Friends of Park Surgery.

We used a number of different methods to help us understand the experiences of patients who used the service. We spent time talking with people observing interaction between staff and patients. We reviewed records and systems and looked at the environment. There were comfortable waiting areas and a good number of consulting rooms

When registered the provider declared compliance with all outcome areas.

We saw that patients were treated with respect and had treatment options discussed with them.

We saw that there were effective infection control measures in place to prevent the spread of infection.

We looked at the processes that the practice had in place to ensure the people who used the service were protected from abuse. These processes ensured staff had an understanding of adult and child abuse and what to do if it was suspected.

We looked at the systems and processes the practice had in place to review the quality of the service provided. These processes ensured information provided was used to improve the service provided.