Park View Surgery Also known as Dr Sukhbinder Singh Deepak

We inspected the practice on 20 August 2019 following our annual review of the information available to us and rated the practice requires improvement overall. We rated the practice as requires improvement for the delivery of well-led services because the leadership, governance and culture did not always support the delivery of high-quality person-centred care. Good for responsive services and we did not rate the practice for effective, due to limited evidence available to the Commission relating to this provider to make a judgement. The provider of this practice changed in May 2021 and inherited the previous inspection rating. We followed up the enforcement action with an announced comprehensive inspection on 12 October 2021.

We carried out an announced inspection on the 12 October 2021 at Park View Surgery. Overall, the practice is rated as Good overall and the key questions are rated as follows:

Safe - Requires Improvement

Effective – Good

Caring – Outstanding

Responsive - Outstanding

Well-led – Good

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

Why we carried out this inspection

This was a comprehensive inspection to follow up on:

• Breaches of regulations and recommendations identified in the previous inspection.
• Ratings carried forward from the previous inspection.

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:

• The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm where they were prescribed high risk drugs. Not all staff had completed infection prevention and control training, there was no embedded process for significant events and the management of historical medicine safety alerts required review.
• Patients received effective care and treatment that met their needs, however some patients with a long term condition required monitoring and review. Practice performance and attainment data was notably higher than local and national averages.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care. The practice had achieved positive patient experience results (GP Patient Survey) throughout the pandemic and demonstrated continued improvement since the last inspection in August 2019 in all indicators.
• Numerous compliments and thank you cards from patients commended all staff for being helpful, friendly, sensitive and reassuring and for receiving an excellent service.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. The practice had designed an annual plan to achieve patient outcomes and performance targets for disease management, such as childhood vaccinations and cervical screening. The plan detailed how many appointments and staff were needed per week and year to meet the performance targets. This included staff annual leave and sickness. This enabled the practice to effectively plan the appropriate appointments for patients. The practice aimed to offer 75 appointments per week per 1000 patients. In addition, the practice also had capacity for emergency and same day face to face appointments.
• The way the practice was led and managed had improved since the last inspection and plans were in place to implement and improve systems.

We found one breach of regulations. The provider must:

• Review and implement systems to ensure care and treatment is provided in a safe way for patients.

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