We carried out an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:
Because of the assurance received from our review of information we carried forward the ratings for 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.
We provided the practice with Care Quality Commission feedback cards prior to the inspection and we received 21 completed cards. Patients were extremely positive about their experiences, practice staff and the care and treatment they received.
We have rated this practice as good overall and good for all population groups.
We found that:
- Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
- The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
- Staff had the skills, knowledge and experience to deliver effective care, support and treatment.
- Staff worked together and with other organisations to deliver effective care and treatment.
- There was compassionate, inclusive and effective leadership at all levels. This included working with and supporting the practice Patient Participation group (PPG).
- The practice had a clear vision and set of values that prioritised quality and sustainability.
- The practice had a culture which drove high quality sustainable care.
- There were clear responsibilities, roles and systems of accountability to support good governance and management.
- There were clear and effective processes for managing risks, issues and performance.
The areas where the provider should make improvements are as follows. The provider should:
- Should review the practice arrangements for ensuring staff have access to a Freedom to Speak Up Guardian.
- Continue to review and monitor the data that falls below the Clinical Commissioning Group (CCG) and national averages.
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