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Archived: Dr Kieran Pressley Requires improvement Also known as Totley Rise Medical Centre

The provider of this service changed - see new profile


Inspection carried out on 12 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Requires Improvement overall. (Previous inspection 19 May 2015 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The rating for safe and well-led is requires improvement. The concerns which led to these ratings apply to everyone using the practice, including all the population groups.

Older People – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those retired and students – Requires Improvement

People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people living with dementia) – Requires Improvement

We carried out an announced comprehensive inspection at Dr Kieran Pressley, known as Totley Rise Medical Centre on 12 December 2017 as part of our inspection programme.

At this inspection we found:

  • The practice had not completed a legionella risk assessment to manage, mitigate and monitor the risk of legionella.
  • No enivironmental risk assessments had been completed of systems or premises.
  • The fire risk assessment had not been reviewed since July 2016. Actions identified on the last fire risk assessment had not been completed. For example, there had been no fire drills completed and staff had not received fire safety training updates. 

  • Safety alerts were disseminated but there was no record of what actions had been taken as a result.
  • Staff had administered immunisations without a patient specific direction (PSD) from a prescriber.
  • There was no record of actions taken from the infection prevention and control (IPC) audit completed in 2015. .

    We observed the same cleaning equipment was used for cleaning all areas in the premises including clinical areas increasing the risk of cross infection and cleaning equipment was not colour coded as recommended in the National Patient Safety Agency specifications for cleanliness in the NHS for primary care medical premises. Sharps bins were not labelled appropriately in two of the three consulting rooms seen as outlined in the Health Technical Memorandum 07-01- safe management of healthcare waste.

  • The provider ensured that care and treatment was delivered according to evidence-based guidelines and most staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.  However, some staff had not received or were overdue fire safety and IPC training.

  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • The governance arrangements did not always operate effectively as there was a lack of monitoring and oversight of processes and systems to manage safety in the practice effectively. There was a leadership structure in place and staff told us they felt respected, supported and valued. They felt part of a team and were proud to work at the practice.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Ensure all staff receive an appraisal as part of the appraisal process.
  • Consider keeping a record of all staff meetings.
  • Review staff training in infection control and fire safety.
  • Record in the patient record what follow up activity has been completed for children who have not attended hospital appointments.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 19 May 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the practice of Dr Kieran Pressley on 19 May 2015. Overall the practice is rated as good.

Specifically we rated the practice as good in providing safe, effective, caring, responsive and well-led care for all of the population groups it serves.

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Patients said they found it easy to make an appointment with a preferred GP, there was continuity of care and urgent appointments were available the same day.
  • Patients said they were treated with compassion, dignity and respect and were involved in care and decisions about their treatment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Overall risks to patients were assessed and well managed.
  • Information about services and how to complain was available and easy to understand. Complaints were addressed in a timely manner and the practice endeavoured to resolve complaints to a satisfactory conclusion.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients.

However, there were also areas of practice where the provider needs to make improvements. Specifically, the provider should:

  • Ensure all staff have a formalised annual appraisal and a personal development plan in place.
  • Ensure all staff acting in the capacity of a chaperone have appropriate training.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

CQC Insight

These reports bring together existing national data from a range of indicators that allow us to identify and monitor changes in the quality of care outside of our inspections. The data within the reports do not constitute a judgement on performance, but inform our inspection teams. Our judgements on quality and safety continue to come only after inspection and we will not make judgements on data alone. The evidence tables published alongside our inspection reports from April 2018 onwards replace the information contained in these files.