We carried out an announced comprehensive inspection at Collingwood Family Practice on 28 January 2020 as part of our inspection programme. On 12 December 2019 we undertook a review of the governance arrangements at provider level and reviewed the corporate policies, procedures and systems in place across the organisation. During this inspection, we looked at whether governance arrangements were embedded and used by staff working at the practice.
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 good overall and good for all population groups.
We found that:
- Patients received effective care and treatment that met their needs and was planned and delivered according to evidence-based guidelines.
- Staff had the skills, knowledge and experience to deliver effective care, support and treatment and worked together and with other organisations to deliver effective care and treatment.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients were satisfied with the service they received from the practice. They told us they could get appointments when they needed them, often the same day.
- Staff felt valued and supported in their work. There was a good working relationship between the practice and the patient participation group.
- The culture of the practice and the way it was led and managed drove the delivery and improvement of high-quality, person-centred care.
- Staff told us that the management team were approachable, and they felt valued and supported in their work.
- There was a focus on continuous learning and improvement at all levels of the organisation. For example: sharing learning from audits, significant events and complaints across the staff team.
Whilst we found no breaches of regulations, the provider should:
- Record completion of required actions on risk assessments.
- Provide additional fire exit signs around the building.
- Collate all information relating medicine and safety alerts within one document.
- Display information regarding the complaint procedure within the practice.
- Record the response to complaints, including detailing of how to escalate the complaint if required.
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