Avisford Medical Group

We carried out an announced comprehensive inspection of Avisford Medical Group on 27 February 2019. The overall rating for the practice was good. The practice was also rated good for providing safe, effective, caring and responsive services. All the population groups were rated good. It was, however, rated as requires improvement for providing well-led services. This was because: -

• Learning from significant events and complaints was not always used or shared effectively to make improvements.

The full comprehensive report on the 27 February 2019 inspection can be found by selecting the ‘all reports’ link for Avisford Medical Group on our website at .

After the inspection in February 2019 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

This inspection was an announced focused inspection carried out on 20 September 2019 to ensure that the practice was now complying with the regulations.

Overall the practice continues to be rated as good, however it is still rated as requires improvement for providing well led services.

At this inspection our key findings were: -

• There was some evidence to show that the practice regularly discussed significant events and complaints and shared the findings and some of the lessons learned with staff.

However, we also found: -

• Whilst the practice had a policy for reporting significant events, it did not make clear what constituted a significant event or how they should be prioritised.
• The practice did not maintain an accurate or complete chronological log or summary of significant events to enable it to monitor action and identify trends.
• Records of significant events were brief and there was limited evidence to show whether enough information gathering or investigations in to the root cause had taken place.
• Appropriate action and lessons learned were not always identified.
• There was limited evidence to show that agreed actions had been monitored or implemented.
• The practice did not maintain a clear audit trail or accurate log of complaints
• Complaints records indicated that learning was not always widely shared and that a culture of openness and transparency was not embedded.
• The practice had not implemented a system for assuring that all safety alerts received were disseminated appropriately and acted on.

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.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

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

We previously carried out an announced comprehensive inspection at Avisford Medical Group on 20 April 2018. The overall rating for the practice was requires improvement. This was because arrangements were not in place to ensure services were provided in a safe way to patients, effective arrangements for ensuring good governance were not in place and the practice needed to ensure staff received the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties. The full comprehensive report on the 20 April 2018 inspection can be found by selecting the ‘all reports’ link for Avisford Medical Group on our website at .

After the inspection in April 2018 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

We carried out an announced comprehensive follow up inspection at Avisford Medical Group on 27 February 2019. At this inspection we followed up on breaches of regulations identified at our previous inspection on 20 April 2018.

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 in four of the key questions except for the well led domain, where the practice still requires improvement. The practice is rated as good for all population groups.

We rated the practice good for providing safe, effective caring and responsive services because:

• Risks to patients, staff and visitors were assessed, monitored and managed in an effective manner.
• 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.
• Practice performance against the quality and outcomes framework indicators showed that practice performance was higher than average in several areas, for example for patients suffering with dementia.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patient survey results were positive and higher than average in some areas including patients overall experience of the practice.
• Patients found the appointment system easy to use and reported that they could access care when they needed it.
• There was an active patient participation group in place who told us that they had seen improvements within the practice. They told us the practice listened to patient views and acted on them.
• Staff were positive about working in the practice and felt valued and supported in their roles. They had access to essential training and were encouraged to develop in their roles.

We rated the practice requires improvement for well led because:

• Learning from significant events and complaints was not always used or shared effectively to make improvements.

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:

• Improve the uptake for cervical screening to ensure at least 80% coverage in line with the national target.
• Keep a central record that provides an audit trail of action taken in response to external medicine and patient safety alerts.

Dr Rosie Bennyworth BS BMedSci MRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.