11 September 2019
During a routine inspection
We carried out an announced focused inspection at Drs Yap, Hughes and Michael on 11 September 2019, following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a change to the quality of care provided since the last inspection.
This inspection focused on the following key questions:
- Safe
- Effective
- Responsive
- Well-led
Because of the assurance received from our review of information we carried forward the ratings for the following key questions:
- Caring
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 requires improvement overall.
We rated the practice as requires improvement for providing safe and well led services because:
- There were some systems and processes in place to keep people safe. However, these were not always identified, sufficiently well managed or embedded to ensure their effectiveness.
- There was a lack of effective leadership oversight to ensure good governance. The practice did not always have clear and effective processes for managing risks, issues and performance.
We rated the practice as good for providing effective and responsive services because:
- The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care. Patient feedback was consistently positive. This included the results of the national GP survey, CQC comment cards and patient interviews.
- Overall, patients could access care and treatment in a timely way. Some patients reported that access to appointments was difficult, the practice was taking action to address this.
The areas where the provider must make improvements are:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
- Continue to promote and explore ways to improve the uptake of cancer screening.
- Continue to explore ways to improve access for patients.
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