We decided to undertake an inspection of this service on 19 September 2019 following our annual review of the information available to us. This inspection looked at the following key questions; was the service providing effective and well led services for the registered patient population. We decided not to inspect whether the practice was providing safe, caring or responsive services as there was no information from the annual regulatory review which indicated this was necessary.
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 good for all population groups.
We found that:
- The practice had an ethos of delivering care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- Audit was used but needed further development to establish systematic identification of patterns and themes.
- Staff were developed and supported with a range of training in line with their role to ensure services were of high quality.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- Governance systems were operated including quality improvement initiatives.
- The practice was engaged in local initiatives and worked effectively alongside partners in the local healthcare and social care system.
Whilst we found no breaches of regulations, the provider should:
- Review governance systems to include annual systematic analysis of significant events to identify trends and take corrective action.
- Set up a system to carry out onward checks to see if the two week waits/urgent referral patients have received a timely response from the hospital.
- Continue to implement quality and outcomes framework exception reporting quality improvement actions, to ensure patients with long term conditions receive timely reviews and improved health outcomes.
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
Overall summary