Pinehill Surgery

We carried out an announced inspection at Pinehill Surgery on 9 November 2021. Overall, the practice is rated as Good.

The ratings for each key question are as follows:

Safe - Good

Effective - Good

Well-led - Good

Following our previous inspection on 17 September 2019, the practice was rated Requires Improvement overall and requires improvement for Safe and Well-led. It was rated Good for Effective, Caring and Responsive.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Pinehill Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection, to follow up on:

• The key questions of Safe, Effective and Well-led.
• Areas followed up including any breaches of regulations or ‘shoulds’ identified in previous inspection.

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 was 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 and
• information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm. Improvements had been made since the last inspection and there were sufficient staff and systems in place to promote patient safety.
• Patients received effective care and treatment that met their needs. Our reviews of records showed patient records were clearly and accurately completed and their care was regularly reviewed
• The way the practice was led and managed promoted the delivery of high-quality, person-centred care. The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic, whilst also embedding changes initiated after the last inspection. Areas we had identified for improvement at the last inspection had been addressed and there was a structured workforce to implement and progress further improvements. Patients could access care and treatment in a timely way.

Whilst we found no breaches of regulations, the provider should:

• Promote the resumption of regular multidisciplinary meetings with partners in patient care.
• Formally record decisions on what emergency medicines GP partners decided were not needed and why.
• Encourage a more active incident reporting culture.
• Ensure audits of changes made in response to safety alerts are carried out, to test whether the changes are sustained.
• Continue to invite patients for cervical screening to achieve 80% take-up.
• Meetings should have a standard agenda to ensure key topics are prompted and discussed regularly.
• Reinstate routine engagement with patients and the Patient Participation Group.

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