This practice is rated as Requires Improvement overall. (Previous inspection 14 January 2016 – Good overall, requires improvement for Well Led)
The key questions are rated as:
Are services safe? – Requires Improvement
Are services effective? – Requires Improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Requires Improvement
We carried out an announced comprehensive focused inspection at Abbeyslade PMS – Dr Chand on 11 April 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was carried out in line with our next phase inspection programme.
At this inspection we found:
- The practice did not have clear systems to manage risk so that safety incidents were less likely to happen. For example, we found that the practice had not followed its cold-chain policy or national guidelines on the management of vaccines.
- There was evidence that care and treatment was delivered according to evidence-based guidelines. However, arrangements in place to formally review the effectiveness and appropriateness of the care provided was not consistent.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- The practice offered a flexible range of appointments and services.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
- The practice proactively sought feedback from staff and patients, which it acted on. There was a clear leadership structure and staff felt supported by management. There were regular clinical meetings which were well documented.
- There was a lack of governance arrangements to ensure that quality assurance processes were in place which led to improvements in patient outcomes.
The areas where the provider must make improvements are:
- Ensure care and treatment is provided in a safe way to patients.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- Ensure that persons employed at the practice have received appropriate training.
The areas where the provider should make improvements are:
- Review systems in place to increase the uptake of all standard childhood immunisations and cervical screening.
- Continue to take steps to improve practice waiting times during surgery.
- Consider ways to increase the number of elderly patients on the palliative care list and improve partnership working with the local palliative care team.
- Review the process aimed at identifying patients with caring responsibilities to be able to provide appropriate support and signposting.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice