The Care Quality Commission
  • Doctor
  • GP practice

Cirencester Health Group

Overall: Good read more about inspection ratings

The Avenue Surgery, 1 The Avenue, Cirencester, Gloucestershire, GL7 1EH (01285) 653122

Provided and run by:
Cirencester Health Group

All Inspections

26 May 2022

During an inspection looking at part of the service

We carried out an announced follow-up inspection at Cirencester Health Group on 26 May 2022. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Well-led - Good

Following our previous inspection in October 2021, the practice was rated Good overall and for all key questions except safe which was rated Requires Improvement.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Cirencester Health Group on our website at www.cqc.org.uk

Why we carried out this inspection.

This inspection was a follow-up inspection to follow up on:

  • The breach identified at the last inspection in October 2021.
    • Ensure care and treatment is provided in a safe way for patients. For example, ensure systems for monitoring patients are consistently followed prior to the prescribing of medicines and review the process for completing medicine reviews. Monitor and address the risks to patients who displayed indications of atrial fibrillation.

How we carried out the inspection.

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • What we found when we inspected
  • Information from our ongoing monitoring of data about services and
  • Information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall

We found that:

  • Issues identified at the last inspection had been addressed.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centered care.

Whilst we found no breaches of regulation the practice should:

  • Continue to action plans to address the remaining backlog in patient summarising.
  • The practice should continue to encourage patient uptake in cervical screening.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

14 October 2021

During an inspection looking at part of the service

We carried out an announced inspection at Cirencester Health Group on 14 October 2021. We carried out remote searches of clinical records and documentation on 20 September 2021.

Following our previous inspection on 27 November 2019, the practice was rated Requires Improvement overall and for the effective and well led key questions but Good for the safe, caring and responsive key questions.

At this inspection (October 2021) we found improvements had been made and the provider compliant with the regulations from the 2019 inspection. However, we found a new area in breach of regulation. We re-rated the following key questions:

Safe - Requires Improvement

Effective - Good

Well-led - Good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Cirencester Health Group on our website at www.cqc.org.uk

Why we carried out this inspection.

This inspection was a follow-up inspection to follow up on:

  • The key questions effective and well led were followed up including any breaches of regulations or ‘shoulds’ identified in previous inspection
  • We also reviewed the safe key question.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall and for all population groups with the exception of People with long-term conditions which was rated as requires improvement.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. However, the prescribing of medicines had not always be carried out safely as patients on complex and high risk medicines had not consistently had appropriate monitoring.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We found one breach of regulation.

  • Regulation 12 HSCA (RA) Regulations 2014 Safe care and Treatment.

Ensure care and treatment is provided in a safe way for patients. For example, ensure systems for monitoring patients are consistently followed prior to the prescribing of medicines and review the process for completing medicine reviews. Monitor and address the risks to patients who displayed indications of atrial fibrillation.

The provider should:

  • Implement a system to demonstrate all staff had attended a fire drill within an appropriate time scale.
  • Consistently make sure patient confidential and personal information is stored securely
  • Continue to embed and monitor systems to summarise patient records in a timely way.
  • Review the system for providing staff knowledge of the major incident plan.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

27 Nov 2019

During an inspection looking at part of the service

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change (either deterioration or improvement) to the quality of care provided since the last inspection.

This inspection focused on the following key questions:

  • Is the service effective?
  • Is the service well led?

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

  • Is the service safe?
  • Is the service caring?
  • Is the service responsive?

We have rated the practice as requires improvement overall.

We have rated the practice as requires improvement for providing effective and well led services because:

  • The practice did not have effective oversight of patients who had been exception reported.
  • The practice had not identified actions to improve uptake of diabetic health reviews.
  • Processes to identify and mitigate risk were not effective and consistent.
  • Systems to ensure all staff had the appropriate authorisations to administer medicines were not embedded.
  • Processes to ensure complaints were responded to in line with guidance and practice policy were not embedded.
  • Policies did not always contain up to date information.

We have rated the practice as requires improvement for patients with long-term conditions, working age people (including those recently retired and students) and People experiencing poor mental health (including people with dementia). All other population groups have been rated as good.

The areas where the provider must make improvements are;

  • 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;

  • Establish systems to improve cervical screening uptake.
  • Establish systems to improve uptake for diabetic health reviews.
  • Monitor the effectiveness of actions taken to improve exception rates for patients with mental health conditions.
  • Establish systems to review policies and procedures in a timely manner.
  • Continue processes to update CQC registration to reflect all recent changes.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Rosie Benneyworth

Chief Inspector of PMS and Integrated Care

19 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Avenue Surgery on 19 April 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.
  • Risks to patients were assessed and well managed.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • 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 good facilities and was well equipped to treat patients and meet their needs.

  • The leadership team led by example and encouraged cooperative, supportive relationships among staff so they felt respected, valued and supported.

  • 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice