Updated 6 March 2024
Date of assessment: 30 May to 17 July 2024. We conducted this assessment due to receiving information of concern. We assessed 11 quality statements across the safe, effective, responsive and well-led key questions and have combined the scores for these areas with scores from the last inspection. The assessment included completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements). Reviewing patient records to identify issues and clarify actions taken by the provider. Requesting evidence from the provider, speaking with staff and visiting the main location At this assessment we found that leaders had implemented new systems, practices, and processes to help keep people safe but these were in their infancy. The practice had a system for appropriate and safe use of medicines and was developing this to demonstrate it was effective. Prior to the assessment the practice had not identified all outstanding patient medicine reviews which were apparent in the CQC clinical searches. Once identified the practice took action to respond to these and embed new systems. The practice had not consistently learned from significant events and was taking action to sustain and embed improvements in this area. Referral processes were not consistently effective but action was being taken to mitigate this risk through the introduction of a specific team to review tasks and referrals. Managers investigated concerns appropriately but learning was not always shared to make and embed improvement. Action had been taken to address this. Patients did not always find it easy to access the practice by telephone however, the practice had introduced new systems and processes to address this and were monitoring these to measure improvements. The leaders had recently changed the governance at the practice and introduced monthly patient safety meetings.