You are here

Wollaston Surgery Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 4 December 2019

We carried out an announced comprehensive inspection at Wollaston Surgery on 28th and 29th October 2019.

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 Requires Improvement overall.

  • The practice had a leadership structure but some of the governance arrangements in place were not effective.
  • Patients were at risk of harm because some systems and processes in place were not effective to keep them safe.
  • Risks to patients were assessed but the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe.
  • Feedback from people who use the service and stakeholders was positive. Out of 30 comments cards completed by patients registered at the practice, 22 patients expressed high levels of satisfaction about all aspects of the care and treatment they received. The feedback from comments cards we reviewed said patients felt they were treated with by professional and caring staff who with compassion, dignity and respect.

We rated the practice as Requires Improvement for providing a Safe service because we found:-

  • Patients were at risk of harm because some systems and processes in place were not effective to keep them safe. For example, patient safety alerts.
  • The practice did not always have an effective system in place to safeguard service users from abuse and improper treatment.
  • Risks to patients were assessed but the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. For example, fire and legionella.
  • Standards of cleanliness were not always met.
  • The system in place to monitor patient’s health was not formalised to ensure they were reviewed in a timely manner to ensure medicines were being used safely and followed up on appropriately.

We rated the practice as Good for providing Effective services because we found:-

  • 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.
  • Staff were aware of current evidence based guidance.
  • There was limited evidence of clinical audits to demonstrate quality improvement.

We rated the practice as Requires Improvement for providing a well-led service because we found:-

  • We found a lack of leadership and governance relating to the overall management of the dispensary.
  • There was a governance framework in place but it did not always support the delivery of the strategy and good quality care. For example, patient safety alerts, infection control, staffing levels, medicine reviews, long term conditions and meeting minutes.
  • The arrangements in place for managing risks was always effective.
  • Meeting minutes did not contain enough detail to provide information to staff.
  • The practice had a number of policies and procedures to govern activity.
  • There was limited evidence of innovation or service development. There was also no evidence of learning and reflective practice.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Ensure all staff have received a yearly appraisal.
  • Monitor exception reporting to ensure new system is embedded.
  • Ensure the business continuity plan has the risks mitigated.

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

Inspection areas

Safe

Requires improvement

Effective

Good

Caring

Good

Responsive

Good

Well-led

Requires improvement
Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good