The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Alec Yolomoni Kapenda Also known as Abbey Surgery

Overall: Inadequate read more about inspection ratings

60 Abbey Street, Accrington, Lancashire, BB5 1EE (01254) 382224

Provided and run by:
Dr Alec Yolomoni Kapenda

All Inspections

21 March 2018

During a routine inspection

This practice is rated as inadequate overall. (Previous inspection July 2016 – Good)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires Improvement

Are services responsive? – Inadequate

Are services well-led? - Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those recently retired and students – Inadequate

People whose circumstances may make them vulnerable – Inadequate

People experiencing poor mental health (including people with dementia) - Inadequate

We carried out an announced comprehensive inspection at Dr Alec Yolomoni Kapenda (Abbey Surgery) on 21 March 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had failed to implement clear systems to manage risk meaning safety incidents were more likely to happen. When incidents did happen, the practice was unable to demonstrate how it learned from them or improved processes.

  • Care and treatment were not consistently delivered in line with evidence based best practice guidelines.

  • Patient consultation records were not appropriately maintained.

  • The practice lacked adequate leadership capacity.

  • Governance structures were not sufficient to ensure safe and effective care was offered. There were gaps in practice policies and procedures to govern key activities.

  • The practice had failed to review the effectiveness and appropriateness of the care it provided.

  • Medicines were not managed in a safe way according to guidance. We saw evidence that some patients were prescribed medicine without appropriate medication reviews and health checks being completed.

  • Staff treated patients with compassion, kindness, dignity and respect during face to face interactions.

  • Patients were universally positive about access to the service and told us they found the appointment system easy to use. They were able to access care when they needed it.

  • There were gaps in the practice’s approach to managing and responding to patient complaints.

  • There was a lack of managerial oversight of staff training and we found some gaps in the mandatory and role specific training completed by clinicians.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.

  • Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.

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

  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

2 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

This is a focused desk top review of evidence supplied by Dr Alec Yolomoni Kapenda, within the key question safe conducted on 2 November 2016.

The practice was initially inspected on 5 July 2016. The inspection was a comprehensive inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (HSCA). At that inspection, the practice was rated ‘good’ overall. However, within the key question safe, a number of areas were identified as requires improvement, as the practice was not meeting the legislation at that time; Regulation 12 Safe care and treatment.

At the inspection in July 2016 we found that; patients were being put at risk due to inadequate risk assessment and mitigatory actions which included:

Gas and electrical safety checks had not been carried out. There was no risk assessment or stock control system for emergency drugs and equipment, and some emergency drugs were out of date. Prescription pads were not stored securely and there was no adequate audit trail of individual prescriptions held by the GP. Blind pull cords were not risk assessed and health and safety risk assessments had not been reviewed since 2011. There was no audit trail to evidence actions taken in response to nationally issued safety alerts and clinical coding in patient medical records did not demonstrate that diagnoses were recorded and medical conditions were adequately reviewed when medication reviews were undertaken.

The practice supplied an action plan and a range of documents which demonstrated they are now meeting the requirements of Regulation 12 Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found the practice to be good in providing safe services. Overall, the practice is rated as good.


Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Alec Yolomoni Kapenda on 5 July 2016. 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 an effective system in place for reporting and recording significant events.
  • The practice treated all patients as individuals and was responsive to personal need, including directing patients to appropriate social care as well as health care.
  • Risks to patients were not always assessed and managed, for example no safety checks had been made for utilities such as gas and electricity and health and safety risk assessments had not been reviewed since 2011.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • 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 and how to complain was available and easy to understand. The practice had received no formal written complaints in recent years, but was responsive to informal complaints.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had implemented a policy that children were always seen without appointments to improve access for parents with concerns about their children’s health.
  • 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 provider was aware of and complied with the requirements of the duty of candour although continuity plans required updating to reflect the requirements.
  • The practice had made improvements in some patient outcomes, such as prescribing and diabetes management, though audit was not used to continuously improve patient outcomes.
  • We noted that the indemnity cover in place did not include the practice nurse; however this was addressed during the inspection.

We saw one area of outstanding practice:

The practice recognised that many older and vulnerable patients had become socially isolated and implemented individual solutions to support these patients. For example, some patients received telephone calls before holiday periods to offer support and encouragement; one patient had become a volunteer within the practice and in 2015 the practice also worked with the patient participation group to host a Christmas party which was attended by 30 – 40 older patients.

The areas where the provider must make improvement are:

  • Emergency medicines and equipment must be risk assessed and a stock control system introduced to ensure they are always in date.
  • Prescription pads must be stored securely, including reducing the quantity carried outside the practice.
  • Update health and safety risk assessments to ensure all potential risks have been identified and mitigating actions taken, to include blind pull cords and undertaking legionella risk assessment.
  • Implement a record system for recording nationally issued safety alerts and actions taken.
  • Improve the quality of coding in patient medical records including demonstrating that diagnoses are recorded and that medical conditions have been adequately reviewed when medication reviews are undertaken.

The areas where the provider should make improvements are:

  • Formalise quality improvement work and conduct regular clinical audits and re-audits to improve patient outcomes.
  • Review and update procedures and guidance, including the business continuity plan to incorporate effective reporting under the Duty of Candour requirements.
  • Formalise the review process for significant events to ensure that all learning has been implemented.
  • Complete the work to introduce multi-disciplinary meetings and engage with the wider work to support patients who are terminally ill through collaborative working.
  • Introduce a practice website to improve patient access to practice and wider health information.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

24 September 2013

During a routine inspection

One the day of our announced inspection we spoke with six people who had attended for appointments, the GP, the practice manager and two administration/reception staff. We also spoke with a professional who was undertaking a clinic at the practice and three members of the Patient Participation Group (PPG).

The majority of people spoke highly of the practice and of the way they were treated by staff. Comments included, 'It's a well-run surgery. One of the things I like is that it's very personal and friendly', 'You can always get an appointment' and 'The doctor always has time for you'.

We found people's views had been taken into account in the way the service was provided and that they were treated with dignity and respect.

Staff had received training in safeguarding children. Although staff had not received training in safeguarding adults they were aware of the procedure to be followed should they have any concerns that abuse was occurring.

Staff told us they enjoyed working at the practice and felt well supported by both the GP and practice manager. One person commented, 'I love coming to work'.

We found the provider had systems in place to monitor the quality of service provision.