We carried out an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:
Are services at this location effective?
Are services at this location well-led?
Because of the assurance received from our review of information, we carried forward the ratings for the following key questions:
Are services at this location safe?
Are services at this location caring?
Are services at this location responsive?
At the last inspection on 11 November 2015 we rated the practice as good overall.
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.
- information from the provider, patients, the public and other organisations.
We have rated this practice as good overall, and requires improvement for effective services.
We rated the practice as requires improvement for effective services because:
- Some patients suffering with long-term conditions and those suffering from poor mental health were not receiving regular monitoring and reviews as highlighted by low QOF data. Exception reporting was also high in some areas.
We rated the practice as good for providing well-led services because:
- Patients’ were assessed, and care and treatment was provided in line with current legislation, standards and evidence-based guidance.
- The practice routinely reviewed the effectiveness and appropriateness of the care provided.
- Staff supported patients with care and advice to live healthier lives.
- Effective care and treatment was coordinated with other organisations.
- Staff had the knowledge and skills to carry out their roles.
- Staff members were encouraged to be involved in any development or change and improvements at the practice.
- Leadership at the practice promoted compassionate, person-centred, inclusive, and effective care at all levels.
- Governance arrangements showed there were clear responsibilities, of roles and systems of accountability to support the services provided at the practice.
- Patients told us they were involved in decisions about their care.
- There were clear and effective processes to manage risks, and issues in performance.
- The practice involved the public, staff and external partners to support them provide sustainable care. The patient participation group told us the practice were always open to their ideas and allowed them to be involved in many practice developments.
The areas where the provider should make improvements are:
- Improve the monitoring and review of patients with long-term conditions and those suffering from poor mental health. Implement an improved system for exception reporting patients.
- Improve the uptake of patients eligible for cervical cancer screening , and ensure evidence of all screening is documented in patient records.
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