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 effective
- are services well-led
Because of the assurance received from our review of information, we carried forward the ratings for the following key questions:
- are services safe
- are services responsive
- are services caring
We based our judgement on 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 good for all population groups; with the exception of families, children and young people and working age people (including those recently retired and students), which were rated as being requires improvement.
We found that:
- There were effective and comprehensive systems and processes in place to support good governance of the practice.
- Staff were aware of their roles and responsibilities. They were supported with training and development suitable for their individual roles.
- There was evidence of effective leadership and management. Leaders and managers had a good understanding of the challenges they faced regarding the provision of primary care services for their patient population.
- There was a range of risk assessments, data analysis, audits and reviews to support quality improvement. Any areas for improvement were identified and acted upon.
- Staff were committed to providing high-quality, accessible services.
- Patients received structured reviews of their care and treatment. They received appropriate care and advice to support management of their symptoms and were signposted to other avenues of support as appropriate.
- The practice was proactive in the development of the local primary care network to support the provision of services for their community.
- Patient comments we received on the day of inspection were generally positive about the practice and the service they received.
The areas where the provider should make improvements are:
- Review fire evacuation processes to support patients with mobility difficulties in navigating the stairs in the event of a fire.
- Continue to monitor exception reporting for the Quality and Outcomes Framework
- Continue to monitor and improve the uptake rates for childhood immunisations.
- Continue to monitor and improve the uptake rates for cancer screening.
Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Rosie Benneyworth BM BS MDedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care