The Care Quality Commission
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Archived: Hove Park Villas Surgery

Overall: Requires improvement read more about inspection ratings

The Surgery, 18 Hove Park Villas, Hove, East Sussex, BN3 6HG (01273) 776245

Provided and run by:
Hove Park Villas Surgery

All Inspections

18 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Hove Park Villas Surgery is rated as requires improvement overall. (Previous focused follow up inspection on 9 October 2016 rated as good overall and for safe services and comprehensive inspection on 9 July 2015 rated good overall, requires improvement for safe services and good for effective, caring, responsive and well-led services).

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

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 – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those recently retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

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

We carried out an announced comprehensive inspection at Hove Park Villas Surgery on 18 December 2017. The inspection was carried out as part of our inspection programme.

At this inspection we found:

  • The practice had 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.

  • The practice ensured that care and treatment was delivered according to evidence- based guidelines.

  • Staff involved and treated patients with compassion, kindness, dignity and respect.

  • The practice had appropriate facilities and was well equipped to treat patients and meet their needs.

  • Patients said they were able to book an appointment that suited their needs. Pre-bookable, on the day appointments, home visits and phone consultation services were available.

  • The practice recognised that the patient’s emotional and social needs were as important as their physical needs.

  • Recruitment procedures were generally well established, however there was no recruitment file in place for one member of staff.

  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

  • Staff had not been provided with appropriate training according to the records we reviewed on the day of inspection.

  • Staff had not received up to date appraisals.

  • Staff were positive about working in the practice.

  • Patient survey results were positive and higher than average in a number of areas.

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

  • Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences.

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

  • 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.

  • Ensure specified information is available regarding each person employed.

  • 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:

  • The practice should improve their procedure for identifying patients who are also carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

7 October 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 9 July 2015. Breaches of Regulatory requirements were found during that inspection within the safe and domain. After the comprehensive inspection, the practice sent us an action plan detailing what they would do to meet the regulatory responsibilities in relation to the following:

  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Ensure that the fire detection and alarm system meets the current fire safety legislation.
  • Ensure health and safety audits are undertaken to safeguard patients and staff who enter and work at the premises.

We undertook this focused desktop inspection on 7 October 2016 to check that the provider had followed their action plan and to confirm that they now met regulatory requirements. A desktop inspection is when we request information from the registered provider to check that they have taken action to meet regulations without a visit to the location.

This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Hove Park Villas Surgery on our website at www.cqc.org.uk.

This report should be read in conjunction with the last report published in November 2015.

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

  • We saw evidence that employment checks (Disclosure and Barring Service (DBS)) were now in place for staff.
  • We saw evidence that there was a new effective system in place for the detecting and notification of fires in the practice meeting the current fire safety legislation.
  • We saw evidence that the practice had a system in place that ensured health and safety audits were undertaken.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

9 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hove Park Villas Surgery on 9 July 2015. Overall the practice is rated as good.

Specifically, we found the practice required improvement for providing safe services. The practice was found to be good for providing well-led, effective, caring and responsive services. It was also good for providing services for the six population groups.

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.
  • Risks to patients were assessed and well managed
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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.
  • 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 proactively sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must;

  • Ensure recruitment arrangements include all necessary employment checks for all staff.
  • Ensure that the fire detection and alarm system meets the current fire safety legislation.
  • Ensure health and safety audits are undertaken to safeguard patients and staff who enter and work at the premises.

The provider should;

  • Ensure the systems for obtaining feedback from patients are developed and maintained.
  • Ensure staff training records are improved to provide accessible information on the training status for each staff member.
  • Ensure that all staff who are acting as chaperones are risk assessed and if necessary receive an enhanced criminal records check via the Disclosure and Barring Service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

27 May 2014

During a routine inspection

Hove Park Villas Surgery is a GP practice with approximately 4,000 registered patients situated in the Hove area of Brighton. The practice provided a range of services for patients, which included new patient health checks and clinics for family planning and child health. Patients of Hove Park Villas Surgery were signposted to and well supported by local community support groups.

The majority of the patients we spoke with gave positive feedback about the practice and staff. The practice regularly sought feedback from patients. We reviewed the results of feedback taken in May 2014. This showed patients were consistently pleased with the service they had received.

There was an inconsistent approach to safety. The practice had responded to safeguarding concerns and had processes and procedures to keep patients safe. Effective systems were not always in place to ensure patients were protected from the associated risks of infection control and medicines management. Learning from incidents and complaints was limited and not shared widely or recorded appropriately.

The care and treatment patients with long term conditions received was not always supported by effective systems to achieve positive outcomes. Robust monitoring processes, including clinical audit, and continuous improvements were not always followed. There was some evidence of multi-disciplinary working and collaborative care. The practice delivered care and treatment mostly in line with recognised best practice and guidelines.

Patients were treated with dignity and respect. All of the patients we spoke with reported that they felt supported and well cared for. Staff demonstrated a compassionate and caring attitude and had built good relationships with their patients.

The practice had a basic understanding of the different patient groups within the practice and the local Brighton and Hove population and were responsive to their needs. There was good access to appointments for the GP and nurse. Patients were supported to access the right care at the right time.

Overall the practice was not well led. Robust governance systems which ensured the practice continuously improved the quality of their services and safeguarded high standards of care were not clear and had not been reviewed. There was a lack of effective arrangements to systematically identify and manage risk. The approach to service delivery and improvement was focused on the short term.

Hove Park Villas Surgery did not always proactively assess and monitor patient needs for the specific population groups. However, patients in all of these groups were seen by the practice and there was evidence which demonstrated the practice offered appropriate support to patients from some of these groups.     

We found that the practice was not meeting three of the essential standards of quality and safety in relation to Assessing and monitoring the quality of service provision; Requirements relating to workers and Supporting workers. We have asked the practice to send us a report, setting out the action they will take to meet these safety standards. We will check to make sure that action is taken.

During our inspection we looked at how well services are provided for specific groups of people and what good care looks like for them. The population groups we reviewed were:

•      Older people

•      People with long-term conditions

•      Mothers, babies, children and young people

•      The working-age population and those recently retired

•      People in vulnerable circumstances who may have poor access to primary care

•      People experiencing a mental health problems

We found the practice provided a responsive service for some patients within each population group.

The Surgery, 18 Hove Park Villas, Hove, East Sussex, BN3 6HG.