All inspections: The Acorn & Gaumont House Surgery

Date of assessment: 18 June to 19 June 2024. The Acorn & Gaumont House Surgery is an NHS GP practice located in Southwark, South London in an area of high deprivation. There were approximately 9,000 people registered with the service at the time of our assessment. We last rated this service under our previous methodology on 25 March 2022. The practice was rated inadequate overall (Inadequate for safe and well led key questions, good for caring and responsive and requires improvement for effective) and was placed in special measures. A focused inspection was carried out in July and September 2022, to ensure the issues identified had been addressed, however the practice was not rated during the inspection.

For this assessment we focused on the four key questions of safe, effective, responsive and well-led and have combined the scores for these areas with scores from the last rated inspection. This service has been in Special Measures since 25 March 2022. The provider demonstrated improvements that have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in special measures. However, the provider remains in breach of one regulation in safe care and treatment and we found a further breach in good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.

We carried out an announced focused inspection at The Acorn & Gaumont House Surgery on 14 July 2022 to follow up on concerns found at our inspection on 23 March 2022.

Following our previous comprehensive inspection on 23 March 2022, the practice was rated inadequate overall (Inadequate for Safe and Well led key questions, good for Caring and Responsive and requires improvement for providing Effective services).

Two warning notices were issued to the provider following the inspection undertaken on 23 March 2022. This was to ensure that the provider was aware of our concerns and that action was taken quickly to address these concerns and mitigate risks to patients.

A requirement notice was issued for the additional concerns which related to breaches identified. The level of risk stemming from these concerns was not considered to be sufficient to require additional enforcement action.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Acorn & Gaumont House Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this announced focused inspection on 07 July 2022 at the Acorn & Gaumont House Surgery to check whether the provider had addressed the issues in the warning notices and now met the legal requirements. At this inspection we found the breaches of regulation in our warning notices had now been complied with. This report covers our findings in relation to those specific areas, is not rated, and does not change the current ratings held by the practice.

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 shorter 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.
Information from the provider, patients, the public and other organisations.

Following our methodology we have not rated the practice at this inspection.

We found that:

The provider had implemented a sustainable action plan to address the issues we identified at the previous inspection. At this inspection, leaders demonstrated improved oversight of their responsibilities in relation to medicine management and prescribing.
The practice had made improvements to medication review processes to ensure that patients prescribed high risk medicines were being monitored in accordance with guidelines.
Staff had received appropriate training for their roles.
There were effective arrangements to prevent, detect and control the spread of infections, including those that are health care associated.
Systems for the safe storage of medicines had improved.
The provider had improved oversight of systems to manage safety alerts
The overarching governance framework had improved.

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

We carried out an announced inspection at The Acorn & Gaumont House Surgery on 25 March 2022. Overall, the practice is rated as inadequate.

Set out the ratings for each key question

Safe - Inadequate

Effective – Requires improvement

Caring - Good

Responsive - Good

Well-led - Inadequate

Following our previous inspection on 6 May 2021 and a remote clinical records review on 4 May 2021, the practice was rated requires improvement overall, and for the Safe, Effective, Caring, Responsive, and Well-led key questions. We served two requirement notices for breaches of Regulation 12 of the Health and Social Care (Regulated Activities) Regulations 2014 (Safe care and treatment) and Regulation 17 of the Health and Social Care (Regulated Activities Regulations 2014 (Good governance).

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Acorn & Gaumont House 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 breaches of regulations and covers our findings in relation to the actions we told the practice they should take to improve.

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 Inadequate overall.

We found that:

Clinical and internal audit processes were inconsistent in their implementation and impact. For example, the provider did not have effective oversight of systems to manage safety alerts.
There were concerns that patients did not receive care, treatment and monitoring for their conditions in line with current guidance and recommendations.
There were some risks that were not well managed, related to safety risks in the building which were managed by another organisation.
Systems for reviewing children on the practice’s child protection register had improved.
The practice had not met targets for cervical screening and childhood immunisations. However, there were robust recall systems and performance against these targets was continually reviewed and monitored.
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.
Although GP patient survey results to questions about access to appointments remained below local and national averages, the practice had acted on patient feedback.
The provider had implemented systems and process in response to the findings of our previous inspection. However, the governance arrangements in place were not effective, especially in relation to identifying, managing and mitigating risks.

We found breaches of regulations. The areas where the provider must make improvements are:

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.
Ensure that persons employed at the practice have received appropriate training.

The areas where the provider should make improvements are:

Continue to implement a programme to improve uptake for cervical screening and childhood immunisations.
Improve compliance with policies and procedures; for example, the prescribing policy.
Improve recording of DNACPR decisions and improve oversight of documenting the decisions made.
Continue to encourage patients to become members of the patient participation group.

(Please see the specific details on action required at the end of this report). Warning notices were issued to the provider following the inspection undertaken on 25 March 2022. This was to ensure that the provider was aware of our concerns and that action was taken quickly to address these concerns and mitigate risks to patients.

Requirement notices were issued for the additional concerns which related to breaches identified. The level of risk stemming from these concerns was not deemed to be sufficient to require additional enforcement action.

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 Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced inspection at The Acorn & Gaumont House Surgery. A remote clinical records review was undertaken on 4 May 2021, a short site visit was completed on 6 May 2021 and interviews with staff were held remotely on 5 May 2021 & 11 May 2021. Overall, the practice is rated as Requires Improvement.

Safe - Requires Improvement

Effective - Requires Improvement

Caring - Requires Improvement

Responsive - Requires Improvement

Well-led - Requires Improvement

Following our previous comprehensive rated inspection on 12 March 2020, the practice was rated Requires Improvement overall; requires improvement for effective and responsive and good for safe, caring and well led.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Acorn & Gaumont House 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 concerns identified at our last inspection. Specifically:

There was no system to monitor the recording of patient consent
National GP survey scores were below local and national averages in relation to access.
The practice had not met targets for cervical screening and childhood immunisations.

There were no breaches of regulation identified at our last inspection.

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 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 have rated this practice as Requires Improvement overall and Requires Improvement for all population groups.

We found:

Expired emergency equipment; though this was replaced following our inspection.
Emergency medicines were missing; though one of these was ordered on the day of our inspection and risk assessments for the missing medicines were provided after our inspection.
Although the vast majority of patients on high risk medicines whose records we looked at had appropriate monitoring completed there were a small number of patients whose monitoring was overdue. However we considered the risks associated with this monitoring not having been completed to be low.
The provider was unable to demonstrate that they had completed a DBS check for a locum pharmacist until after our inspection. The check showed that the DBS was completed over three years ago.
Both of the records we check of children on the practice’s child protection register suggested that the practice were not proactively reviewing children on this register. The practice told us that they had review their safeguarding register following our inspection and that these two records were an outlier and all other safeguarding patients had been reviewed.
Some of the care plans we looked at for patients with dementia, learning diabilities and palliative care lacked sufficient detail in order to be effective. The practice told us that following our inspection they had reviewed and made improvements to the care planning templates used.
Patients with chronic kidney disease were not always been coded correctly.
Performance against targets for cervical screening and childhood immunisations, though significantly improved from our last rated inspection, were still below target. The practice was continuing to focus on making improvements in this area.
Performance against targets for patients with mental health conditions and COPD were below local and national averages. The practice had devised strategies including working with their local primary care network and doing remote reviews in an effort to improve this.
Patient satisfaction with care and treatment and access to services was below local and national averages.
Oversight, governance and leadership around the issues above was lacking.

However, we also found that:

The was a programme of quality improvement activity.
There was a supportive and inclusive culture that focused on staff development.
The practice had reached out to certain communities within the locality to provide advice and counselling around vaccine hesitancy and delivered COVID-19 vaccines to these communities.
Practice staff had volunteered to deliver food and medicines to vulnerable patients during the pandemic who were shielding or at risk.

We found breaches of regulations. The provider must:

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

The provider should:

Review systems around safeguarding to ensure that all patients on safeguarding registers are periodically reviewed.
Continue with work to improve performance against targets for cervical screening and childhood immunisation.
Review patients with chronic kidney disease to ensure patients are correctly coded and being followed up appropriately.

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

We carried out an GP focused inspection at The Acorn & Gaumont House Surgery on the 14 December 2020 as part of our inspection programme.

This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk in light of the Covid-19 pandemic. This was conducted with the consent of the provider. Unless the report says otherwise, all information contained within this report was obtained remotely from the provider.

We previously inspected The Acorn & Gaumont House Surgery on 12 March 2020. At this time, we rated the practice Requires improvement overall. Details of this report can be found by selecting the ‘all reports’ link for The Acorn & Gaumont House Surgery on our website at www.cqc.org.uk.

The focused inspection looking at safe and well-led undertaken on 14 December 2020 did not review the ratings for the key questions or for the practice overall as this was a focused inspection undertaken as part of ongoing monitoring.

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.

At this focused inspection we found:

There was an effective system for managing patients on high risk medicines.
Clinical record reviews were completed appropriately.
There were clear staffing structures, with all staff being aware of roles and responsibilities.

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

This practice is rated as requires improvement. (Previous rating July 2019 – inadequate)

The key questions are rated as:

Are services safe? – good

Are services effective? – requires improvement

Are services caring? – good

Are services responsive? – requires improvement

Are services well-led? - good

We carried out an announced comprehensive inspection at, The Acorn & Gaumont Group Practice on 12 March 2020. Following a previous comprehensive inspection in July 2019, the practice had been placed in special measures as we had noted significant safety concerns. We issued a requirement notice in respect of a breach of regulation 12 (safe care and treatment) and 17 (Good Governance) of the Health and Social Care Act 2008 (regulated activities) Regulations 2014.

We first inspected the practice on 18 January 2017, the practice was rated requires improvement overall and was issued a requirement notice for breach of regulation 17 due to the practice being below local and national averages for health outcomes relating to diabetes, hypertension, and poor mental health. Outcomes for patients with learning disabilities were low. Published data also highlighted that patients rated the practice below local and national averages for consultations with GPs, and general satisfaction with the service.

A comprehensive inspection was carried out on 12 April 2018 to follow-up on the concerns raised at the January 2017 inspection. The practice was found to have made improvements and was rated good overall and requires improvement for the caring key question. A requirement notice for breach of regulation 17 was issued because the practice had not taken sufficient action in response to poor national patient survey results in some areas.

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 and for the effective, and responsive key questions. The safe, caring and well-led key questions were rated as good. The population groups: families, children and young people, older people, people, people with long-term conditions, people whose circumstances may make them vulnerable, people experiencing poor mental health and working age people were all rated requires improvement.

The reports of all the previous inspections can be found by selecting the ‘all reports’ link for The Acorn & Gaumont House Surgery on our website at www.cqc.org.uk.

We rated the practice requires improvement for providing effective services because:

The practice had not met the minimum 90% for all four child immunisation uptake indicators.
The practice was below the CCG and national average in three of the five cancer indicators and below the 70% uptake rate for cervical cancer screening.

The practice was rated as requires improvement for providing responsive services because:

The practice’s GP patient survey results had improved since the last inspection. However, there were areas where they are tending towards a negative variation.
The practice had taken steps to improve access to patients by restructuring their appointment system. However, the results from these measures are yet to be reflected.

We rated the practice good for providing safe services because:

The practice had developed a robust safety alert and significant event process.
The practice had developed an auditable system to oversee incoming correspondence.
The practice managed patients on high-risk medicines according to evidence-based guidance.

We rated the practice as good for providing caring services because:

The practice had identified 1% of the people on the practice list as carers.
CQC comment cards were positive about the kindness and compassion displayed by staff.
The practice had improved their GP patient survey results concerning, patients’ overall experience at the practice and patient involvement in decisions about their care and treatment.

The practice was rated good for providing a well-led service because:

Leaders were aware of the challenges and had acted to implement improvement strategies.
There was an effective and comprehensive process to identify, understand, monitor and address current and future risks.
The practice made effective use of internal and external reviews, and learning was shared effectively and used to make improvements.

There were areas where the practice should make improvements:

Put a plan in place to monitor the recording of consent from patients.
Improve areas identified in the national GP patient survey as scoring below the national average.
Take action to improve the take up rate of cervical screening for eligible women.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence

tables for further information.

The Acorn & Gaumont House Surgery is a provider registered with CQC.

We carried out an inspection of the provider on 11 July 2019 to follow up concerns identified on our previous inspection which was carried out in April 2018.

At that inspection we identified the following concerns:

The practice had not taken sufficient action in response to poor national patient survey results in some areas.

The practice was rated as good overall and requires improvement for services that are caring. We issued a requirement notice in respect of a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (regulated activities) Regulations 2014

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 Inadequate overall and inadequate for all population groups

We rated the practice as inadequate for providing safe services because:

The systems in place for managing patients prescribed medicines, including high risk medicines, did not ensure adherence to guidance or that patients remained safe.
A review of records indicated that there was an inconsistent approach to management of safeguarding concerns and some staff were unable to outline what would constitute a safeguarding concern.
There were systems in place to report significant events and we saw evidence of discussion of events in practice meetings. However not all staff were clear on the practice process for reporting significant events and we found examples where significant events were either not documented or learning was not clear.
Appropriate recruitment checks had been taken for staff employed at the service.
Risks associated with the premises were well managed and the provider had oversight of those risks managed by a third party.
The provider had adequate arrangements in place to respond to emergencies including patients who presented with sepsis.
Some tests results had not been actioned due to an IT/administrative oversight and there was no system to audit the work of non-clinical staff who reviewed and filed incoming clinical correspondence.

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

Reviews of patient records indicated that patients with chronic disease were not always having regular timely reviews, patients who had NHS health checks were not being referred for further assessment and diagnosis where appropriate and there was a limited evidence of oversight and review of the work of clinical staff.
One staff member we spoke with did not understand current guidance around consent.
There was evidence of quality improvement activity.
Staff were receiving regular appraisals.
Effective joint working was in place. The practice held multidisciplinary meetings with other health and social care organisations that aimed to provide a holistic package of care for those with complex needs.
All staff had completed the required mandatory training and staff were undertaking continue professional development activities to ensure their knowledge was up to date.

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

Although national GP patient survey data indicated that some patients did not feel that they were listened to and some were not satisfied with their overall experience; the practice’s own internal survey, CQC comment cards and interviews with patients indicated that patients felt that staff treated them with kindness and respect and involved them in decisions about their care.

We rated the practice as inadequate for responsive services because:

Complaints were managed in a timely fashion and detailed responses were provided; although some complaints we reviewed did not contain contact information for external organisations patients could contact if they were dissatisfied with the practices’ response.
Comments from the national GP patient survey, CQC comment card and interviews with patients indicated that some patients found it difficult to access care and treatment at the practice. The practice had taken steps to improve access in response to feedback from patients.

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

Effective governance was lacking in key areas of operation which exposed patients to risk of harm.
Not all risks were not adequately considered and mitigated.
The provider had an active patient participation group and had completed their own internal patient survey.
There was evidence of continuous improvement or innovation.
Staff provided positive feedback about working at the practice which indicated that there was a good working culture.

The areas where the provider must make improvements are:

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.
Ensure patients are protected from abuse and improper treatment

The areas where the provider should make improvements are:

Make all staff aware of legislation and guidelines related to seeking consent.
Encourage uptake of cancer screening programmes.
Improve and expand systems for reviewing clinical consultations.
Review staffing levels and ensure staffing is sufficient to be able to provide adequate access and carry out regulated activities safely.

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.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence tables for further information.

This practice is rated as Good overall. (Previous inspection 18 January 2017 – Requires Improvement)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Requires Improvement

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at The Acorn & Gaumont House Surgery on 12 April 2018 this was to follow up on breaches of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 identified at our last inspection completed on 18 January 2017.

The concerns related to published data which showed that the practice was below local and national averages for health outcomes relating to diabetes, hypertension, and poor mental health. Outcomes for patients with learning disabilities were low. Published data also highlighted that patients rated the provider below local and national averages for consultations with GPs, and general satisfaction with the service. In response to our findings we issued a requirement notice for breaches of regulation 17.

At this inspection we found:

That the practice had made significant improvement in respect of clinical outcomes. Though the practice had gathered internal feedback which was positive and had taken action in response to the national patient survey after the last inspection; the most recent national patient survey still showed that the practice was rated below local and national averages in respect of some aspects of care provided.

The practice did not have a clear protocol in place for the management of sepsis and some staff we spoke with were not able to outline the red flag warning signs of sepsis. However a protocol was put in place and displayed in clinical rooms and reception shortly after our inspection.
The practice had clear systems to manage risk in most instances so that safety incidents were less likely to happen. On most occasions when incidents did happen, the practice learned from them and improved their processes. However action had not been taken in response to risks associated with legionella until after our inspection.
Performance against clinical targets had shown significant improvement. Published data for 2016/17 showed improvement in all areas, though the practice were still not in line with local and national performance. However unverified data provided by the practice for 2017/18 showed that the practice were in line with national clinical performance in almost all areas.
The practice routinely reviewed the effectiveness and appropriateness of the care it provided through clinical audit to ensure that care and treatment was delivered according to evidence- based guidelines. The practice was not routinely auditing individual consultations although we saw evidence of systems being developed to do this.
National patient survey scores related to compassion, kindness, dignity and respect were below local and national averages. Although no action was taken by the practice in response to feedback regarding clinical staff the practice had completed their own internal survey which indicated that satisfaction had improved. Comment cards were mainly positive about the care received and patients we spoke with provided mixed feedback.
Some patients found it difficult to access appointments and get through to the surgery on the telephone. The practice had taken action in response to this feedback and their own internal patient survey indicated improvement with patient satisfaction.
There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider Must make improvements are:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

The areas where the provider should make improvements are:

Implement a system to enable review of clinical consultations.
Work to improve uptake of cervical screening in line with target set by Public Health England.
Have oversight of risk management activities undertaken by third parties.
Continue to review the appropriateness of emergency medicines held on site.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Acorn & Gaumont House Surgery on 18 January 2017. Overall the practice is rated as requires improvement.

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

There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events; however, there was no effective system in place for ensuring that safety alerts from external organisations were actioned. Other risks had been assessed and managed well.

Staff assessed patients’ needs and delivered care in line with current evidence based guidance; however, patient outcomes for health indicators related to diabetes, hypertension and poor mental health were below local and national averages. Outcomes for patients with learning disabilities were also low.

Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. We requested, but were not provided with, records of information governance and fire safety training for two members of staff; this training was completed shortly after our inspection.

The majority of patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment; however, the practice was rated below average for some aspects of consultations with GPs, the helpfulness of receptionists and their overall experience of the service.

Patients said they had not always found it easy to make an appointment or reach the practice by telephone.
Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns, but two out of five complaints we reviewed had not been responded to in a timely manner.

The practice had good facilities.

There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.

The provider had a number of policies in place but we identified instances where it had not followed its recruitment policy.

The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

Assess, monitor and improve performance, patient outcomes, access, and patient satisfaction with the service, and implement an effective strategy to ensure the delivery of good quality care.

The areas where the provider should make improvement are:

Implement an effective system to ensure that safety alerts are actioned.
Review and improve how patients with caring responsibilities are identified and recorded on the clinical system to ensure that information, advice and support is made available to them.
Monitor and review changes made in response to patient feedback, specifically to improve waiting times and access to care for patients.
Implement recruitment arrangements that include all necessary employment checks, and maintain on-going training for all staff (including the maintenance of relevant records) in order to protect patients from any associated risks to their health and welfare.
Respond to complaints in a timely manner.
Conduct regular performance reviews for all staff, and follow practice policies.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

The Acorn & Gaumont House Surgery

All Inspections

During an assessment under our new approach

14 July 2022 and 22 September 2022

During an inspection looking at part of the service

25 March 2022

During a routine inspection

Clinical record review 4 May 2021, site visit 6 May 2021, staff interviews 5 May 2021 & 11 May 2021

During a routine inspection

14 December 2020

During an inspection looking at part of the service

12 March 2020

During a routine inspection

11 July 2019

During a routine inspection

12 Apr 2018

During a routine inspection

18 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice