The Care Quality Commission
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Archived: Kensington Road Surgery

Overall: Requires improvement read more about inspection ratings

148 Kensington Road, earlsdon, Coventry, West Midlands, CV5 6HY (024) 7667 2466

Provided and run by:
Kensington Road Surgery

Important: The provider of this service changed. See new profile

All Inspections

9 October 2023

During a routine inspection

We carried out an announced inspection at Kensington Road Surgery on 9 October 2023.

Overall, the practice is rated as Requires improvement.

The ratings for each key question:

Safe – Requires improvement.

Effective – Good.

Caring – Requires improvement.

Responsive – Requires improvement.

Well-led – Good.

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 in person and on the phone
  • 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 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 Requires improvement overall.

We found that:

  • The practice had a backlog of medicine monitoring and reviews for patients prescribed certain high risk medicines and patients prescribed medicines to treat specific long term conditions. Processes to identify patients that needed a new course of treatment for a long term condition, such as diabetes, were not always effective. Although the practice had identified the issues and had a plan in place, plans were ongoing. Actions were in their infancy and were yet to be embedded.
  • The practice had a plan to address a backlog of summarisation of new patient notes but this work was ongoing.
  • The practice had improved access and the overall experience for patients, but there was limited evidence on the positive impact on patient experience.

However we also found that:

  • There was an effective system to identify and safeguard people from abuse. Clinical staff received regular updates, training and took steps to ensure they were familiar with the most recent clinical guidelines.
  • We observed staff dealt with patients with kindness and respect.
  • Patients could access care and treatment in a timely way.
  • There was a clear leadership structure and staff felt supported by management.
  • The practice team demonstrated a commitment to learning and improvement at all levels of the organisation.

The provider MUST:

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

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

18 July 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kensington Road Surgery on 24 August 2016. The overall rating for the practice was good but required improvement for providing effective services. The full comprehensive report on the 24 August 2016 inspection can be found by selecting the ‘all reports’ link for Kensington Road Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 18 July 2017 to confirm that the practice had carried out their plan to make the improvements required that we identified in our previous inspection on 24 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is now rated as good in all areas.

Our key findings were as follows:

  • The practice had reviewed their recall process for the management of long term conditions and introduced a monitoring process to review ongoing progress and achievement.
  • The GPs had effective systems for dealing with pathology results and a written protocol had been introduced.
  • The practice had introduced an audit programme and tracker demonstrating changes and improvements in care.
  • All staff were aware of the fire and safeguarding procedures and had received the appropriate training. There was a system to ensure training was updated within the required timescales.
  • All staff were aware of the location of emergency equipment and procedures and a fire drill had been carried out.
  • The complaints policy had been updated and made available for patients to view.
  • The practice had reviewed their patient list and identified and made contact with patients who may have been carers and as a result increased the carers’ register from 55 to 79. There was a carers’ board in the waiting area providing information of local carers’ support.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

24 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kensington Road Surgery on 24 August 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 which staff were aware of.
  • Risks to patients were assessed and well managed, and the practice had systems in place to manage safety alerts.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Clinical staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. Some training for reception staff was outstanding in areas such as safeguarding, infection control and information governance. However, the practice had plans in place to ensure this took place. There was also some inconsistency in the approach from the GPs regarding recording actions from pathology results and an agreed more robust system was required.
  • Levels of patient satisfaction with the practice were high. 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 were available on the practice website. There was also information in reception regarding services, but there was no information about how to complain. However, patients we spoke with told us they would know how to make a complaint if they needed to.
  • 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 adequate 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 engaged well with staff and sought feedback from both staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Review and introduce a robust system and policy for dealing with pathology results consistently
  • Review the recall process for management of long term conditions and consider appropriate exception reporting and the practice view regarding care plans to reflect a more accurate position of effectiveness of care.
  • Ensure every member of staff is aware of all items of emergency equipment.
  • Ensure update training is completed in line with practice plan regarding safeguarding and fire.
  • Ensure that more two cycle audits are undertaken to demonstrate improvement.
  • Ensure the complaints procedure is updated and made available for patients to view in the practice.
  • Consider ways of increasing the number of carers identified on the register.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice