Pump Lane Surgery Also known as The Surgery

Updated 22 November 2022

Pump Lane Surgery is located at 13 Pump Lane, Rainham, Gillingham, Kent, ME8 7AA.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Kent and Medway Integrated Care System and delivers General Medical Services (GMS) to a patient population of about 2,200.

The practice is part of a wider network of GP practices: Medway Gillingham South Primary Care Network (PCN).

Information published by Public Health England shows that deprivation score within the practice population group is eight (out of 10). The lower the score, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 94% white, 3.5% Asian, 0.7% Black, 1.5% Mixed and 0.4% Other.

There are higher than average number of patients over the age of 65 when compared with the national and local averages. The number of patients under the age of 18 and aged 18 to 64 closely mirrors the local and national averages.

The practice consists of one GP (male), one practice nurse (female) and one practice manager. The practice is supported by a team of reception and administration staff.

The practice is open between 8am and 6.30pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments. The practice offers extended hours every Tuesday between 6.30pm and 7.30pm.

Extended access is provided locally by the PCN, where late evening and weekend appointments are available. Out of hours services and urgent care problems are provided by NHS 111 and Medway on Call Care (MedOCC) when GP surgeries are closed.

Updated 22 November 2022

We carried out an announced comprehensive inspection at Pump Lane Surgery on 11 February 2022. The overall rating for the practice was Requires Improvement.

After our inspection in February 2022, the provider wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

We carried out an announced focused follow up inspection on 1 November 2022 to follow up the breaches of regulation found in our previous inspection in February 2022. Overall, the practice is rated as Good.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services well-led? – Good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Pump Lane Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from the previous inspection.

How we carried out the inspection

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 inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was in line with all data protection and information governance requirements.

This included:

• Completing clinical searches on the practice’s patient records system and discussing findings with the provider,
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.

Our findings

Our judgement of the quality of care at this service is based 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 found that:

• The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
• Recruitment checks were carried out in accordance with regulations.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Appropriate standards of cleanliness and hygiene were met.
• There were adequate systems to assess, monitor and manage risks to patient safety.
• Staff had the skills, knowledge and experience to carry out their roles.
• The practice learned and made improvements when things went wrong.
• Patients’ needs were assessed, and care as well as treatment were delivered in line with current legislation, standards and evidence-based guidance.
• Published results showed the childhood immunisation uptake rates for the vaccines given were above the 90% minimum target.
• The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
• The practice involved the public, staff and external partners to sustain high quality and sustainable care.
• Systems for managing safety alerts were effective.
• The practice had a programme of targeted quality improvement and used information about care and treatment to make improvements.

The areas where the provider should make improvements are:

• Continue to implement and monitor the outcome of plans to improve performance relating to antibiotic prescribing.
• Continue to review coding for patients who require regular monitoring.
• Ensure conversations regarding the risks of certain medicatons have been appropriately recorded.
• Review processes to ensure plans for second cycle audits are recorded.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services