The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Ebenezer Timeyin Also known as Thanet Road Surgery

Overall: Good read more about inspection ratings

63 Thanet Road, Bexley, Kent, DA5 1AP (01322) 528221

Provided and run by:
Dr Ebenezer Timeyin

All Inspections

3 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 22 September 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 12(1)(2)(a)(b)(d)(f) Safe care and treatment and regulation 19(1)(b)(2)(a)(3) Fit and proper persons employed of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this desk-based focussed inspection on 3 June 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Dr Ebenezer Timeyin on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe and effective services, however they were rated as requires improvement for well-led services. As the practice was now found to be good for safe and effective services, this affected the ratings for the population groups we inspect against. Therefore, it was also good for providing services for older people; people with long-term conditions; families, children and young people; working age people (including those recently retired and students); people whose circumstances make them vulnerable and people experiencing poor mental health (including people with dementia).

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

  • Risks to patients were assessed and well-managed, including those related to fire, health and safety and responding to emergencies.
  • Recruitment arrangements were robust including those for locum staff.
  • Staff had received mandatory training and update training to be able to carry out their roles effectively, with the exception of safeguarding children’s training for all staff.
  • The practice had a number of updated policies and procedures to govern activity.
  • The practice had sought feedback from patients and had an active Patient Participation Group (PPG).

However there were areas of practice where the provider should make improvements:

  • Ensure that there are systems in place to monitor and improve the quality and effectiveness of the service, including a clinical audit plan and systems to maintain medical and consultation records in line with guidance.
  • Ensure that the practice carries out fire drills in line with the practice’s fire policy and completes all actions identified in the fire risk assessment.
  • Ensure all staff have access to mandatory safeguarding children’s training in line with national recommendations and guidance.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

22 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Ebenezer Timeyin, Thanet Road Surgery on 22 September 2015. Overall the practice is rated as requires improvement.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Most risks to staff and patients had not been fully assured apart from those relating to medicines management and infection control.
  • Patients’ needs were assessed and care was planned and delivered but did not always follow best practice guidance. Staff had received training appropriate to their roles but some mandatory training had not been completed for clinical and non-clinical staff.
  • Data showed patient outcomes were average for the locality. There was evidence that some audits had been carried out with improvements in patient outcomes, although they were not always clearly documented.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments 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 had a number of policies and procedures to govern activity, but some were over five years old and had not been reviewed since. The practice did not hold regular governance meetings.
  • The practice had sought feedback from patients and had an active Patient Participation Group (PPG) with some evidence that changes had been implemented in the practice.

The areas where the provider must make improvements are:

  • Ensure that the practice has clear systems for assessing, managing and monitoring risks including those related to fire, health and safety and responding to medical emergencies.
  • Ensure that all staff receive mandatory training and update training in line with their roles; specifically training for safeguarding children, basic life support, infection control, information governance and fire safety.
  • Ensure recruitment arrangements include all necessary employment checks for all staff including those for locums.

In addition the provider should:

  • Ensure chaperone training is provided and the chaperone policy includes all necessary information about the chaperoning role.
  • Ensure that a system is in place to monitor and track the use of prescription pads in the practice.
  • Improve access to online appointment booking, in line with contractual agreements.
  • Ensure that the practice has access to translation services for patients and promotes this service in the practice.
  • Review the systems in place to ensure that all patients acting as carers are identified.
  • Ensure that information is available to help patients understand how to make a complaint and ensure that complaints are acknowledged in line with contractual obligations.
  • Ensure that all practice policies and procedures to govern activity in the practice are updated and reviewed in a timely way to enable staff to carry out their roles.
  • Ensure that there are systems in place to monitor and improve the quality and effectiveness of the service, including medical records.
  • Ensure that the practice continues to carry out Patient Participation Group (PPG) surveys so that up to date patient feedback and areas for improvement can be identified.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice