Background to this inspection
Updated
28 November 2018
Dr Roy Alexander also known as Marshalls Road Surgery provides a range of primary medical services to the residents of Raunds and surrounding villages. The service is provided from a registered location Dr Roy Alexander, 7 Marshalls Road, Raunds, Wellingborough, NN9 6ET. The practice has a dispensary that serves patients who live more than one mile from a pharmacy.
The regulated activities registered to provide are:
- Diagnostic and screening procedures
- Maternity and midwifery services
- Surgical procedures
- Treatment of disease, disorder or injury
The practice population is predominantly white British and has a lower than average number of patients aged five to 14 years and a higher than average number aged over 65 years. National data indicates the area is one of low deprivation. The practice has approximately 2,580 patients and services are provided under a General Medical Services contract (GMS), this is a nationally agreed contract with NHS England.
The practice has a male principal GP and employs a female practice nurse. There is a practice manager and a team of reception, administrative and dispensing staff.
The practice is open from 8am to 6.30pm Monday to Friday. When the practice is closed out-of-hours services are provided by Integrated Care 24 and can be accessed via the NHS 111 service.
Updated
28 November 2018
This practice is rated as Good overall. (Previous rating 01/2018 – Inadequate)
The key questions at this inspection are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We carried out an announced comprehensive inspection at Dr Roy Alexander also known as Marshalls Road Surgery on 29 January 2018. The overall rating for the practice was inadequate and the practice was placed into special measures for a period of six months. Warning notices were served in relation to breaches identified under Regulation 12 Safe care and treatment and Regulation 17 Good governance. We completed an announced focussed inspection on 17 July 2018 to check on the areas identified in the warning notices
and found that sufficient improvements had been made regarding these.
The full comprehensive report on the January 2018 inspection and the focussed report for the July 2018 inspection can be found by selecting the ‘all reports’ link for Dr Roy Alexander on our website at .
This announced comprehensive inspection on 3 October 2018 was carried out following the period of special measures to ensure improvements had been made and to assess whether the practice could come out of special measures.
At this inspection we found:
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. Staff understood their duty to raise concerns and report incidents and near misses.
- Governance arrangements in the practice had been strengthened. Staff meetings were formalised and policies and procedures had been reviewed and now covered all pertinent areas including business continuity, safeguarding and infection control.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
- All staff were involved in making improvements to the practice. The practice had reviewed its staffing needs and additional staff had been recruited to support the practice manager.
- An infection control audit had been completed. However, the practice had not completed the areas that required attention and did not have an action plan in place to address them.
- Complaints were managed according to recommended guidance. However, the date was not recorded on the letters sent to the complainant.
The areas where the provider should make improvements are:
- Complete the areas that were identified as requiring attention in the infection control audit.
- Review the complaints procedure particularly in relation to the dating of communications to demonstrate the recommended timeframes for responding to complaints are met.
- Develop ways to engage with patients and gather feedback in the absence of a patient participation group.
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
Please refer to the detailed report and the evidence tables for further information.