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The Pinner Road Surgery Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 13 August 2019

We carried out an announced comprehensive inspection at The Pinner Road Surgery on 19 June 2019 as part of our inspection programme.

At this inspection, we followed up on breaches of regulations identified at a previous inspection on 14 May 2018. Previous reports on this practice can be found on our website at: .

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 requires improvement overall and good overall for all population groups, with the exception of working age people (including those recently retired and students) which is rated as requires improvement.

We rated the practice as r

equires improvement for providing safe and well-led services because:

  • Fridge temperatures were not always adequately monitored.
  • The practice had not identified and raised concerns and reported incidents when fridge temperatures were recorded higher or lower than the recommended range.
  • The practice did not have a paediatric pulse oximeter which could be required to enable assessment of a child patient with presumed sepsis.
  • The practice was unable to provide evidence of regular fire drills.
  • We found expired products and several opened and partially used items.
  • The practice was unable to provide documentary evidence of an asbestos survey. This issue was highlighted during the previous inspection.
  • Safeguarding policies were recently reviewed, but they did not include up to date details.
  • The practice was aware of and complied with the requirements of the Duty of Candour.
  • The practice had demonstrated good governance in most areas, however, they were required to make further improvements.

We rated the practice as good for providing effective, caring and responsive services because:

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • The practice’s uptake of the childhood immunisations rates was in line with the national averages.
  • The practice’s uptake of the national screening programme for cervical cancer was below the local and the national averages.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Feedback from most patients and recently published (11 July 2019) annual national GP patient survey results reflected that they were able to access care and treatment in a timely way. However, some improvements were required.
  • The practice was encouraging patients to register for online services and 35% of patients were registered to use online Patient Access.
  • The practice organised and delivered services to meet patients’ needs.
  • Information about services and how to complain was available.

We rated all population groups as good for providing responsive services. We rated all population groups as good for providing effective services, with the exception of working age people (including those recently retired and students) which is rated as requires improvement, because of low cervical screening rates.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Consider how to evacuate patients with mobility problems.
  • Continue to develop a patient participation group (PPG) and increase the frequency of PPG meetings.

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

Well-led

Requires improvement
Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good