This practice is rated as Good overall. (Previous inspection July 2015 – Good)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We carried out an announced comprehensive inspection at Cumberland House Surgery on 11 April 2018 this inspection was carried out as part of our inspection programme.
At this inspection we found:
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
- Patients commented positively on the care received by the practice.
- The practice responded to complaints in a timely and open manner.
- Staff reported there was high staff morale and low turnover of staff.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
We saw areas of outstanding practice:
- The practice had information about an interpreter service available in clinical rooms and waiting areas. The poster explained the service in four different languages and the practice explained the languages chosen represented the majority of the languages spoken by patients registered at the practice.
- The practice had commenced group consultations for patients with diabetes to use clinical time more effectively and to offer this group of patients peer support.
The areas where the provider should make improvements are:
- Carry out more detailed risk assessments with regard to the decision by the practice not to carry out Disclosure and Barring Service (DBS) checks on non-clinical staff to ensure the reason for the decision is clearly documented.
- The extended role of the health care assistant to support GPs with the triage system should be supported by a detailed protocol.
- Carry out a review of children on the child protection register to confirm the reason for inclusion on the register.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice