We had previously carried out an announced comprehensive inspection at Old Fletton Surgery on 25 September 2018. The overall rating for the practice was requires improvement; with requires improvement for safe, effective and well led services. Caring and responsive services were rated good. At this previous inspection, the practice was issued with a requirement notice for Regulation 17 (good governance). The full comprehensive report on that inspection can be found by selecting the ‘all reports’ link for Old Fletton surgery on our website at www.cqc.org.uk.
This inspection was an announced comprehensive inspection, carried out on 4 September 2019, to check improvements identified at the previous inspection had been completed. At this inspection, we found that the practice had demonstrated improvements in most areas, however, they were required to make further improvements.
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 have rated this practice as Good overall and good for all population groups except families, children and young people which we have rated as requires improvement.
We found that
- The practice had taken appropriate action and responded to concerns we identified during our previous inspection.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patient’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice, legislation and technologies. This was monitored to ensure consistency of practice.
- 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-center care.
At this inspection, we rated the practice as requires improvement for the population group of families, children and young people in the effective domain because:
- The practice had reflected on their public health England data and worked proactively to encourage uptake of childhood immunisations. However, at the time of the inspection, achievement in this area was below national targets.
Whilst we found no breaches of regulations, the provider should:
- Continue efforts to identify carers from the practice population to enable this group of patients to access the care and support they need.
- Take action to ensure that the monitoring of medicine fridge temperatures in the dispensary are managed inline with best practice guidelines.
- Review the approach taken in the identification of reporting concerns, safety incidents and near misses in both the practice and dispensary, to be assured that all staff were sufficiently aware of reporting thresholds as stated in the practice policy.
- Continue to monitor security risk assessments ensuring all areas are covered including access to the dispensary.
- Continue efforts to improve the uptake of child immunisations and the rates of cervical screening for eligible women across the practice population.
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