We carried out an announced review at Picton Green Family Practice on 10 & 16 June 2021. Overall, the practice is rated as Good.
The rating for the key question followed up was:
Well-led – Good
Following our previous inspection on 11 December 2019, the practice was rated Good overall and for all key questions but Requires Improvement for providing well led services and the population group of people with long term conditions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Pitcon Green Family practice on our website at www.cqc.org.uk
Why we carried out this review
This review was a follow up review of information without undertaking a site visit inspection to follow up on the key question – Well-led and the population group of people with long term conditions.
We reviewed the breach identified at the last inspection of Regulation 17 HSCA (RA) Regulations 2014 Good governance. The regulation was not being met because:
- There was no clear documented system in place for continued work on improving patient outcomes.
We reviewed the areas where the previous inspection identified that the provider should make improvements, including:
- Systems and processes for managing complaints should contain comprehensive information.
- The whistleblowing policy should be updated to contain all of the information required to support staff to raise concerns about the service.
- Improvements for the uptake of health reviews for patients with long term conditions.
How we carried out the review
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 reviews differently.
This review 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 in line with all data protection and information governance requirements.
This included:
- Reviewing action plans sent to us by the provider.
- Requesting evidence from the provider.
- Speaking with the practice using video conferencing.
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 good overall and for all key questions and population groups.
We found that:
- The breach of Regulation 17 HSCA (RA) Regulations 2014 Good governance had been addressed and clear documented systems were in place to improve patient outcomes.
- Systems and processes for managing complaints contained information for patients and staff.
- The whistleblowing policy had been updated and contained all of the information required to support staff to raise concerns about the service.
Whilst we found no breaches of regulations, the provider should:
- Review and improve their complaints policy to ensure the acknowledgement time frame stated is clear for staff and patients alike.
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