28 November 2019
During an inspection looking at part of the service
We carried out an inspection of this service following our annual review of the information available to us, including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.
This inspection focused on the following key questions:
- are services effective
- are services caring
- are services well-led
Because of the assurance received from our review of information we carried forward the ratings for the following key questions:
- are services safe - good
- are services responsive - good
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 and good for all population groups; with the exception of families, children and young people and working age people (including those recently retired and students), which were rated as being requires improvement.
We found that:
- There were effective systems and processes in place to support good governance of the practice.
- The lead GP and manager were visible, approachable and supportive of staff. Staff reported they felt valued and were positive about working at the practice.
- There was a culture of openness, honesty and transparency.
- There was a good understanding of the areas where they needed to improve, particularly relating to the Quality and Outcome Framework (QOF) indicators.
- The practice manager was pivotal in the development of the Primary Care Network childhood immunisations project, which was aimed at improving uptake rates within the local areas.
- Patient comments submitted via the CQC comment cards were all positive regarding the service, care and treatment they received from the practice.
The areas where the provider should make improvements are:
- Continue to monitor and improve the identification of carers.
- Continue to monitor and improve the uptake rates for childhood immunisations.
- Continue to monitor and improve the uptake rates for cancer screening.
- Formalise the induction programme for new staff.
Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care.