The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Peter Scott Also known as Chester Road Surgery

Overall: Good read more about inspection ratings

406C Chester Road, Kingshurst, Birmingham, West Midlands, B36 0LF (0121) 770 3035

Provided and run by:
Dr Peter Scott

Important: The provider of this service changed. See new profile

All Inspections

23 June 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We first inspected Dr Peter Scott’s surgery also known as Chester Road Surgery on 17 April 2015 as part of our comprehensive inspection programme. During the inspection we found the practice was in breach of legal requirements and placed into special measures. Following the inspection the practice wrote to us to say what they would do to meet the regulations. We undertook a comprehensive follow up inspection on 20 April 2016 to check that they had followed their plan and to confirm that they met the legal requirements. Overall we found improvements had been made to the concerns raised and as a result of the inspection findings the practice was rated as Good. The full comprehensive reports can be found by selecting the ‘all reports’ link for Dr Peter Scott on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 23 June 2017 to confirm that the practice had continued to meet the legal requirements. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. Overall we found the practice continued to meet all the legal requirements and continues to be 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. Staff had regular monthly meetings to discuss significant events and lessons learnt. The practice carried out an analysis of each event with a documented action plan.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety, this included an effective process for monitoring and actioning safety alerts.
  • 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 and the practice had set up a training matrix to monitor that all staff were receiving the appropriate training and updates for their role.
  • Clinical audits demonstrated quality improvement and the practice carried out regular audits to monitor patient outcomes.
  • Results from the July 2016 national GP patient survey showed patients were 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 found it easy to make an appointment and there was continuity of care, with a sit and wait service available each morning and urgent appointments available the same day.
  • The premises proved a challenge due to lack of space, which the staff managed well.
  • 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 GPs encouraged a culture of openness and honesty. The practice had a well established governance framework to support the delivery of safe and effective care.


Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

20 April 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Dr Peter Scott Surgery, also known as Chester Road Surgery on 20 April 2016. This was a follow up to an announced comprehensive inspection at Dr Peter Scott’s practice on 17 April 2015. During the inspection in 2015 we found the practice was in breach of legal requirements. The breaches related to:

Regulation 17 HSCA (Regulated Activities) Regulations 2014 Good Governance

Regulation 18 HSCA (Regulated Activities) Regulations 2014 Staffing

Regulation 19 HSCA (Regulated Activities) Regulations 2014 Fit and proper persons employed

Following the inspection the practice wrote to us to say what they would do to meet the legal requirements. We undertook this inspection on 20 April 2016 to check that they had followed their plan and to confirm that they had met the legal requirements.

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 had been put in place for reporting and recording significant events.
  • Staff had regular monthly meetings to discuss significant events and lessons learnt. The practice carried out an analysis of each event with a documented action plan.
  • Systems and processes had been put in place to keep patients safe and risks to patients were assessed and well managed.
  • Health & safety risk assessments had been completed and action plans were in place.
  • Infection control audit had been completed and we saw evidence that identified actions had been addressed.
  • Information about services and how to complain was available and easy to understand.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment and had received training appropriate to their roles and any further training needs had been identified and planned.
  • The practice had a number of policies and procedures to govern activity, which had been reviewed and updated.
  • All staff were aware of the practice policies and were able to access them via a central point on the practice computers
  • The practice had set up a training matrix to monitor that all staff were receiving the appropriate training and updates to their role.
  • The national GP survey results for January 2016 were higher than the local and national averages.
  • The premises proved a challenge due to lack of space, which the staff managed well.
  • There was a clear leadership structure and a temporary practice manager had been recruited to support the current practice manager and staff felt supported by management and the GPs.
  • Recruitment procedures were in place and the necessary checks had been completed, this also included Disclosure and Barring Service (DBS) checks.

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

17 April 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Dr Peter Scott also known as Chester Road Surgery on 17 April 2015.

The overall rating for the practice is inadequate. This is because the safe and well led domains were rated as inadequate. The practice is also rated as requires improvement for effective and responsive. The service was rated as good for caring for the population it served. It was also rated as inadequate for providing services for the care to older people, people with long term conditions, families, children and young people, the working age population and those recently retired, people whose circumstances may make them vulnerable and people experiencing poor mental health because the concerns which led to these ratings apply to everyone using the practice, including all the population groups.

Our key findings were as follows:

  • The practice had experienced a rapid increase in patient list size with an additional 1200 patients being accommodated in 2011 following the closure of a neighbouring practice. The increase in patients had caused considerable strain on current resources.
  • Patients were at risk of harm because systems and processes were not in place to keep them safe.
  • We saw that there was an infection control policy in place but it did not provide adequate guidance to staff. Staff training records did not show that they had undertaken any recent training in this area to enable them to support each other on infection control although we were told infection control e-learning training was currently being organised.
  • The practice did not have robust systems, processes and policies in place to manage and monitor risks to patients, staff and visitors to the practice. For example we found that the practice had not carried out a health and safety risk assessment and the practice did not undertake effective checks of the building and environment to properly identify any issues that needed to be addressed.
  • Staff were inconsistent about reporting incidents, near misses and concerns and there was very limited evidence of learning and communication with staff when things went wrong.
  • We found the provider did not have suitable arrangements in place to ensure that staff received appropriate training, professional development, supervision and appraisal. Training records were not managed in a way which made it easy to identify and monitor what training staff had received and whether they were up to date with attending the practice’s mandatory courses.
  • The practice could not provide us with any evidence to demonstrate that practice meetings were occurring on a regular basis. A GP told us that the GPs and practice manager had daily meetings, which were not minuted.
  • The practice was unable to demonstrate that staff, other than the GPs had received a Disclosure and Barring Service (DBS) check. In the absence of these DBS checks, no risk assessments had been carried out by the practice.
  • We found that patients were treated with respect and their privacy and dignity was maintained. Patients informed us they were satisfied with the care they received.
  • The practice had limited formal governance arrangements to ensure they could assess and monitor the quality of the service they provided.

Areas of practice where the provider needs to make improvements.

The provider MUST:

  • Ensure there is an effective system in place so that information and documentation required has been obtained before people start working at the practice to confirm if they are suitable to work with patients.
  • Ensure suitable arrangements are in place to support staff to deliver care and treatment safely and to an appropriate standard by receiving professional development and appraisal.
  • Ensure there are effective systems in place to identify, assess the quality of the service and manage risks in order to protect service users, and others, against the risks of inappropriate or unsafe care (by ensuring all risk assessments are in place for example in respect of health and safety).

Action the provider SHOULD take to improve:

  • Ensure all staff acting as a chaperone have appropriate understanding of their duties and responsibilities
  • Ensure staff are aware of the arrangements in place to access translation services should a future need arise for interpreting services.
  • Ensure that any areas identified of improvement for infection control and prevention are implemented through effective action planning
  • Ensure that the practice complaints process is clear and effective and makes it easy for patients to raise any issues or concerns and that the practice encourages feedback from patients in order to evaluate and improve.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again within six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice