Updated 29 April 2024
The date of this assessment was between the 17 to the 19 June 2024. We carried out our on-site assessment on the 19 June 2024. We rated this service under our previous methodology on 20 -22 March 2023 where it was inspected and rated inadequate overall, for key questions safe and well-led; Requires improvement for Effective and Good in Caring. We conducted this assessment as an Enforcement follow up, to ensure that the service was compliant where they were in previous breach of regulations. The service remains rated good for Responsive (we didn’t assess this key question), Requires Improvement for Safe and Well Led and Good in Effective. The service is rated Requires Improvement overall. As per the guidance we identified breach in relation to Good Governance. We assessed 18 Quality statements under the key questions of Safe; Effective and Well Led. This included: Learning culture, Safeguarding ,Safe environments, Safe and Effective staffing, Infection prevention and control; Freedom to Speak up; Shared Direction and culture. During this assessment we found that the way the practice was led and managed promoted the delivery of good quality care although some improvement in the governance arrangements was required with regard to practice policies, system processes and monitoring. The practice had a business plan which detailed their strategy however this has only been recently created therefore evidence of this was not clear. During our assessment we identified concerns around the management of medicines and management of clinical waste. We found concerns around learning improvement and innovation. Learning was discussed at a senior level however not with the wide team. This service has been in Special Measures since 21 June 2023. The provider demonstrated improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.