• Doctor
  • GP practice

Almond Road Surgery - Dr's Wrigley and Chomicka

Overall: Good read more about inspection ratings

Almond Road Surgery Almond Road, St Neots, Cambridgeshire, PE19 1DZ (01480) 473413

Provided and run by:
Almond Road Surgery - Dr's Wrigley and Chomicka

All Inspections

20 July 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Dr’s Bacon, Wrigley & Chomicka on 20 July 2022 Overall, the practice is rated as good.

Safe - Requires improvement

Effective – Good

Caring – Good (carried forward from previous inspection)

Responsive – Good (carried forward from previous inspection)

Well-led - Good

Following our previous inspection on 4 February 2016 the practice was rated Good overall and for all key questions.

The ratings for the key questions caring and responsive are carried forward from the previous inspection, these key questions have not been included in this inspection due to our methodology and no concerns were identified through the monitoring or inspection process.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr’s Bacon, Wrigley & Chomicka on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

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
  • Staff questionnaires

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:

  • The processes in place for linking medicines to conditions was not always effective.
  • The practice had a system for managing safety alerts but had not continued to monitor historical alerts and ensure safe prescribing for all patients.
  • Although the practice and staff told us there was supervision and competency check for clinical staff, we did not see this was always formally recorded for future and proactive learning.
  • Patients received effective care and treatment that met their needs.
  • 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 person-centre care.

We found a breach of regulation. The provider must:

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

In addition, the provider should:

  • Continue to improve the uptake of cervical screening.
  • Continue to monitor and improve prescribing of antibacterial drugs.

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

23/12/2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on 29 June 2015. A breach of legal requirements was found.

Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons’ employed.

The provider did not have an effective recruitment process in place. Staff were employed without relevant back ground checks being carried out. Proof of identification was not available for all staff which corresponds to regulation 19 (2) of the Health and social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider had not ensured that clinical staff were employed with a Disclosure and Barring service (DBS) check and that all relevant background checks were carried out, including on the locum staff and non-clinical staff who carried out chaperone duties.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to ensuring robust processes were in place for the recruitment of staff.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. 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 on our website at www.cqc.org.uk

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

29th June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We conducted a comprehensive announced inspection on 29 June 2015.

Specifically, we found the practice to be good for providing effective, caring, responsive and well-led services. Improvements were needed to ensure that safer recruitment processes were in place and that staff were suitable to carry out the work they were employed for. It was also good for providing services for the older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people living in vulnerable circumstances, and people experiencing poor mental health (including people with dementia).

Our key findings 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, addressed and shared with staff during meetings.
  • Risks to patients and staff were assessed and managed. There were risk management plans in which included areas such as premises, medicines handling and administration, infection control and safeguarding vulnerable adults and children.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles. Staff were supervised and supported as needed and any further training needs had been identified and planned for.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. They told us that access to appointments with GPs and nurses was good and that they were happy with the treatments that they received.
  • Information about services and how to complain was readily available and easy to understand. Complaints were handled and responded to in line with relevant guidelines.
  • 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 needed to make improvements.

Action the provider must take to improve

  • The provider must ensure that staff are suitable to carry out the work they were employed to do. Ensure staff are employed with Disclosure and Barring service (DBS) checks and all relevant background checks are carried out including the locum staff.

Actions the provider should take to improve

  • Ensure staff receive training appropriate to their roles, and any training needs are identified, documented and planned, for example, infection control.
  • Ensure portable appliance testing (PAT) is carried out by a qualified person for the role who has completed appropriate training. They should complete a risk assessment and ensure documentation is kept for audit purposes.
  • Ensure staff personnel files are kept up to date.
  • Ensure infection control audits and a Legionella risk assessment are carried out.
  • Ensure policies are reviewed regularly and are accessible to all staff.
  • Chaperone training should be undertaken by all staff providing this service to patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 October 2013

During a routine inspection

During our inspection on 10 October 2013 we found the service to be welcoming with friendly staff. There was limited written information available for people using the service.

Appointments could be made on line using the practice website, as well as the customary telephone access. There was a daily 'sit and wait' emergency service should people need to see a doctor the same day. We spoke with 11 people who all spoke highly of services provided to them and some people's comments were more positive than others. For instance, most people though the staff were sensitive and helpful, whilst two people commented that staff were not always good at ensuring conversations were not overheard.

People's needs had been assessed and their care and treatment had been planned and delivered in line with their individual wishes. One person said, "I've always been treated well here." Another person said, "All the staff; the doctor, nurses and receptionists are very courteous."

We saw that the vaccines used by the surgery were safely managed.

Staff we spoke with told us they enjoyed working in the practice and felt supported in their work.

We found the premises were spacious, comfortable and had been well maintained and that treatment rooms and consultations room ensured privacy.