We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:
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.
Following our last inspection, in June 2016, we asked the provider to review their arrangements for recording and monitoring staff infection control training. During this inspection we found the provider had addressed this.
At this inspection we have rated this practice as good overall, and good for the effective and well led key questions.
We found that:
- 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. The practice had the second highest screening rates for bowel and breast screening, within the local clinical commissioning group. They had also performed very well against the national averages. The practice’s childhood immunisation uptake rates were also very good.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
- Leaders had a very good understanding of the issues and challenges they faced in developing the practice further, and they had a strong strategy and improvement plan in place to help them do this.
- There was evidence of strong systems and processes for learning, continuous improvement and innovation. Leaders had just introduced a new quality assurance committee system, to help them: address areas of variation in quality; respond to and manage risk; identify areas where further improvements could be made.
Whilst we found no breaches of regulations, the provider should:
- Review the frequency at which all staff receive cardiopulmonary resuscitation training, to bring it into line with guidance issued by the Resuscitation Council (UK).
- Make arrangements for the practice nurses to complete Level 3 safeguarding training, as set out in the Intercollegiate Document, ‘Safeguarding Children and Young People: Roles and Competencies for Healthcare staff’ (January 2019). Also, the provider should review their child safeguarding policy to take account of this guidance, as well as other recent national guidance.
- Review the practice’s whistle-blowing policy, to make sure it complies with the NHS Improvement Raising Concerns (Whistleblowing) Policy.
- Continue to take action to develop an active patient participation group.
Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care