29 January 2020
During an inspection looking at part of the service
We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a change to the quality of care provided since the last inspection.
This inspection focused on the following key questions:
- Effective
- Responsive
- Well Led
Because of the assurance received from our review of information we carried forward the ratings for the following key questions:
- Safe
- Caring
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 received 27 CQC feedback cards about patient care and experience, these cards were given to patients before and during the inspection. Comments made by patients were extremely positive about the services provided and the practice staff. Two negative comments related to a lack of online information for patients and problems with the practice answering their telephones.
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 and used information about care and treatment to make improvements.
- Staff had the skills, knowledge and experience to deliver effective care, support and treatment.
- Care was delivered and reviewed in a coordinated way when different teams, services or organisations were involved.
- The practice actively identified people who may need extra support to live a healthier lifestyle. Staff provided advice and information i.e. leaflets, so people can self-care. This included information in a range of languages to support the local population.
- The practice understood the needs of its local population and had developed services in response to those needs.
- In response to concerns raised by members of the public and patients about access to appointments the practice undertook a detailed investigation into the causes. A number of factors were identified as a root cause to these problems and remedial action was taken.
- There was evidence that complaints were used to drive continuous improvement.
- Practice leaders had the experience, capacity and skills to deliver the practice strategy and address risks to it. They were knowledgeable about issues and priorities relating to the quality and future of the service.
- The practice had a culture which drove high quality sustainable care. There were governance structures and systems which were regularly reviewed and there were clear and effective processes for managing risks, issues and performance.
- The practice engaged with staff and patients to develop services. However, they did not have a Patient Participation Group.
Whilst we found no breaches of regulations, the provider should:
- Consider developing a practice Patient Participation Group which is representative of the local population.
- 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