We carried out an announced inspection at The Sandringham Practice from the 12 July to 22 July 2022. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring - Good
Responsive - Outstanding
Well-led - Good
Why we carried out this inspection
This is the practices first comprehensive inspection following registration with the Commission. We inspected all five key questions.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection as carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A short site visit.
Our findings
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.
- Information from the provider, patients, the public and other organisations.
We have rated this practice as Good overall
We found that:
- The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
- There were adequate systems to assess, monitor and manage risks to patient safety.
- The practice had systems for the appropriate and safe use of medicines, including medicines optimisation.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- 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.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- There were evidence of systems and processes for learning, continuous improvement and innovation.
We have rated the practice outstanding for providing a responsive service because:
- The provider has reviewed the needs of the practice population group and has offered services and events to attempt to meet their needs. Unverified data from the provider demonstrated that 471 patients out of the practice population of 4,350 patients have accessed these services and events. (Over 10%.) Examples of the free services and events funded by the provider which they had made available to the population were:-
- The Children’s Health & Wellbeing Strategy. Which included the offer to all maternity patients a bespoke antenatal and post-natal package of care. Peppa Pig’s Flu Clinic a community event hosted in response to tackling low immunisation levels across the population group and to encourage the uptake of influenzas vaccine by two to three-year-old children. Pawsome Easter Adventure to alleviate the fear associated with visiting the GP practice for children and raise awareness of local health and wellbeing services available to families and their children.
- Patient Education Workshops, an ongoing project, and the aim was to educate the practices population and embed group consulting. Examples of online training was legal workshops (Housing Issues) and nutrition.
- The Community Hub Project, an ongoing project that offered community workshops, for example, with regards to housing disrepair, carers, and strengthening your resilience to mental health. The aim was to respond to the wider determinants of health and wellbeing. The events included a wellness retreat, and weekly yoga and mindfulness clases.
- A Digital Health and Wellbeing Day, the event was responding to the practices increased digital use and digital divide and it increased the patient’s knowledge of local wellbeing services. The event taught patients how to access services digitally, carried out opportunistic health screening and had a range of 30 local services which exhibited.
Whilst we found no breaches of regulations, the provider should:
- Ensure all complaint responses include details of where the complainant can go further if they are unhappy with the practice response.
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