We carried out an announced comprehensive inspection on 12 October 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?
Our findings were:
Are services safe?
We found that this service was not providing safe care in accordance with the relevant regulations.
Are services effective?
We found that this service was providing effective care in accordance with the relevant regulations.
Are services caring?
We found that this service was providing caring services in accordance with the relevant regulations.
Are services responsive?
We found that this service was providing responsive care in accordance with the relevant regulations
Are services well-led?
We found that this service was not providing well-led care in accordance with the relevant regulations
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
Our key findings were:
- Systems and processes were in place to keep patients safe. However, we identified some shortfalls in relation to safeguarding, incident analysis, managing and acting on medicines safety alerts.
- There were no medicine audits carried out to monitor the effectiveness of prescribing.
- Governance arrangements required improvements; there was no program of continuous clinical and internal audit to cover the range of services offered. The sharing of learning from complaints and significant events was not always shared with staff in a consistent way.
- Patients reported being treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
- Patients said they found it easy to make appointments, and were happy with the 24-hour service provided at the practice.
- The clinic had good facilities and was well equipped to treat patients and meet their needs. The service could not evidence how they kept clinicians up to date with current evidence based practice.
- There were no clear arrangements relating to the leadership of the service.
We identified regulations that were not being met and the provider must:
- Ensure effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
You can see full details of the regulations not being met at the end of this report.
There were areas where the provider could make improvements and should:
- Monitor fire exits so that they remain clear of any obstruction.
- Develop quality assurance processes to include two cycle clinical audits for the different specialisms offered at the service to drive improvement.
- Develop a system to monitor prescription stationery.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice