Background to this inspection
Updated
26 November 2018
Rawnsley Surgery is registered with the Care Quality Commission (CQC) as an individual provider and holds a General Medical Services (GMS) contract with NHS England. A GMS contract is a contract between NHS England and general practices for delivering general medical services and is the commonest form of GP contract. The practice is part of the NHS Cannock Chase Clinical Commissioning Group (CCG).
The premise is a single storey purpose built building and is located within the village of Rawnsley in Cannock, Staffordshire. The area has strong and historical links to industry, in particular coal mining. The practice treats patients of all ages and provides a range of general medical services and delivers regulated activities from Rawnsley Surgery only.
At the time of the inspection there were approximately 4400 patients registered at the practice. The practice local area is one of less deprivation when compared with the local and national averages. The area has similar outcomes to the local and national averages in the area profile data from Public Health England. The data compares outcomes living in the area including life expectancy and deprivation. The practice has a slightly lower percentage of registered patients with a long-standing health condition. The practice unemployment levels are comparable with the local and national average. The practice population is predominantly white British (98%).
The practice staffing comprises of:
- One male GP
- A female locum GP
- One advanced nurse practitioner (ANP)
- One practice nurse
- One locum practice nurse
- One health care assistant
- One practice manager
- One part-time advanced clinical pharmacist, funded by NHS England
- A team of eight administrative and reception staff to include a secretary and an apprentice.
The practice is open between 8am and 6.30pm Monday to Friday. Extended opening hours are provided on a Tuesday and Wednesday evening from 6.30pm to 8pm. There is no telephone access after 6.30pm, however patients can ring prior to this time and book an appointment for the late surgery. Routine appointments can be booked in person, by telephone or on-line. Home visits are triaged by a GP or ANP to assess whether a home visit is clinically necessary and the urgency for medical attention.
The practice has opted out of providing cover to patients in the out-of-hours period. Patients are directed to the out-of-hours service, Staffordshire Doctors Urgent Care when the practice is closed. The practice is located approximately 10 miles away from New Cross Hospital, Wolverhampton. There is a minor injuries unit at Cannock Hospital.
The provider is registered to provide the following regulated activities:
Diagnostic and screening procedures, family planning, maternity and midwifery, surgical procedures and treatment of disease, disorder or injury.
Additional information about the practice is available on their website:
www.rawnsleysurgery.co.uk
Updated
26 November 2018
We previously carried out an announced comprehensive inspection at Rawnsley Surgery on 25 September 2017. The overall rating for the practice was good. The practice was rated as requiring improvement in providing safe services. A breach of legal requirement was found and a requirement notice was served in relation to safe care and treatment. The full comprehensive report on the September 2017 inspection can be found by selecting the ‘all reports’ link for Rawnsley Surgery on our website at www.cqc.org.uk
This inspection was an announced comprehensive inspection carried out on 22 October 2018 to confirm that the practice had met the legal requirements in relation to the breach in regulation that we previously identified in addition to the good practice recommendations we made.
This practice is rated as Good overall.
The key questions at this inspection are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
At this inspection we found:
- The practice leaders had taken the findings from the previous CQC inspection to improve the services provided and patient safety and care. Each area for improvement had been actioned and our findings at this inspection showed improvements had been made and sustained.
- The practice had systems, processes and practices in place to protect people from potential abuse.
- There were systems in place for identifying, assessing and mitigating risks to the health and safety of patients and staff. The system for the monitoring of patients on high risk medicines had improved. There was now an effective system in place to ensure that patients on repeat medications received regular and appropriate medication reviews. Also, the process used to track prescriptions across the practice had been strengthened to help minimise the risk of fraud.
- The practice had improved the health and safety arrangements in place with a written fire risk assessment and had completed a hard wire check for the building in line with statutory health and safety regulations. However, further work was required.
- The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However, we identified one incident that had not been considered or investigated as a significant event. However, the incident did not impact on patient safety or care.
- Following the last inspection, the practice had pro-actively identified and increased the number of carers registered and were signposting carers to local support groups.
- Most patients felt staff treated them with compassion, kindness, dignity and respect.
- Some patients reported difficulties getting an appointment.
- The patient participation group (PPG) had recently been re-established to represent the needs of the patients.
- The practice was limited by the size of their facilities; however it was equipped to treat patients and meet their needs.
- Staff had access to training opportunities to equip them in their work. However, staff required updates in essential training.
- The practice management had workforce planned and reviewed the staff skill mix to meet the needs of their patient population.
The areas where the provider should make improvements are:
- Ensure staff are up to date with all essential training and effective systems are in place to monitor staff training.
- Ensure all policies are easily accessible to staff; are in line with local and national guidance and systems are in place to ensure staff have read them.
- Improve the management of incidents.
- Review the approach to meeting the Accessible Information Standard.
- Consider developing an internal patient survey.
- Review the security of clinical rooms.
- Develop a documented business plan to support the practice vison and strategy and achieve priorities.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.