14 July 2022 and 22 September 2022
During an inspection looking at part of the service
We carried out an announced focused inspection at The Acorn & Gaumont House Surgery on 14 July 2022 to follow up on concerns found at our inspection on 23 March 2022.
Following our previous comprehensive inspection on 23 March 2022, the practice was rated inadequate overall (Inadequate for Safe and Well led key questions, good for Caring and Responsive and requires improvement for providing Effective services).
Two warning notices were issued to the provider following the inspection undertaken on 23 March 2022. This was to ensure that the provider was aware of our concerns and that action was taken quickly to address these concerns and mitigate risks to patients.
A requirement notice was issued for the additional concerns which related to breaches identified. The level of risk stemming from these concerns was not considered to be sufficient to require additional enforcement action.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Acorn & Gaumont House Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this announced focused inspection on 07 July 2022 at the Acorn & Gaumont House Surgery to check whether the provider had addressed the issues in the warning notices and now met the legal requirements. At this inspection we found the breaches of regulation in our warning notices had now been complied with. This report covers our findings in relation to those specific areas, is not rated, and does not change the current ratings held by the practice.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A shorter 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.
- Information from the provider, patients, the public and other organisations.
Following our methodology we have not rated the practice at this inspection.
We found that:
- The provider had implemented a sustainable action plan to address the issues we identified at the previous inspection. At this inspection, leaders demonstrated improved oversight of their responsibilities in relation to medicine management and prescribing.
- The practice had made improvements to medication review processes to ensure that patients prescribed high risk medicines were being monitored in accordance with guidelines.
- Staff had received appropriate training for their roles.
- There were effective arrangements to prevent, detect and control the spread of infections, including those that are health care associated.
- Systems for the safe storage of medicines had improved.
- The provider had improved oversight of systems to manage safety alerts
- The overarching governance framework had improved.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services