21 November 2019
Pinehill Surgery is located at Pinehill Road, Borden, GU35 0BS.
The practice provides services under a general medical services contract. The practice has approximately 3,600 registered patients. Borden has some areas of deprivation and the practice has a slightly higher than average population of older people with complex needs. The practice is part of the NHS South Eastern Hampshire Clinical Commissioning Group (CCG).
The practice was previously inspected in January 2019, rated inadequate overall and placed into special measures. Since that inspection the practice has recruited a new practice manager.
Patients had access to a same day access service and an acute visiting service provided by the CCG.
The practice is registered with the Care Quality Commission to carry out the following regulated activities - diagnostic and screening procedures, surgical procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury.
The practice’s clinical team consists of two GP partners with a whole time equivalent of 1.6, one locum nurse and two health care assistants. The administration team is led by a practice manager and consists of four receptionists.
The practice has opted out of providing an out-of-hours service. Patients are directed to call NHS 111 service if they require medical advice out of hours.
You can access practice information online at www.pinehillsurgery.co.uk.
21 November 2019
We carried out an announced comprehensive inspection at Pinehill Surgery on 17 September 2019. We previously inspected the practice on 24 January and rated Pinehill Surgery as inadequate overall. The practice was placed into special measures. This inspection was within six months of the previous inspection and was to determine whether the practice had made sufficient improvements to come out of special measures or whether further action was needed by CQC to close the practice.
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. We have rated Safe, and Well-led as requires improvement and Effective, Caring and Responsive as good.
We rated the practice as requires improvement for providing safe and well-led services because:
- There continued to be a shortage of administrative/reception staff since the last inspection and although systems were working more effectively, staff continued to feel under pressure.
- We found gaps in the security system for blank prescription stationery.
- Evidence did not demonstrate that safety alerts were consistently responded to appropriately.
- We identified information governance breaches during the inspection.
- The practice had not displayed its rating from the previous inspection on either its website or on its premises where patients could see it.
We rated the practice as good for providing effective, caring and responsive care because:
- 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.
- The practice now had an improved programme of quality improvement activity, demonstrating significant improvement since the last inspection.
- Staff worked together and with other organisations to deliver effective care and treatment.
- Staff treated patients with kindness, respect and compassion. Feedback from patients was now positive about the way staff treated people.
- The practice now organised and delivered services to meet patients’ needs.
We rated all population groups, apart from working age people, as good because:
- The practice had created and maintained patient registers, since the last inspection, which enabled them to monitor patient care and provide care which was bespoke to individual population groups such as six monthly reviews.
- The practice now followed up on older patients discharged from hospital.
- Patients with long-term conditions were offered a structured annual review to check their health and medicines needs were being met.
- The practice now had arrangements for following up failed attendance of childrens’ appointments following an appointment in secondary care or for immunisation.
- Patients could book or cancel appointments online and order repeat medication without the need to attend the surgery.
- Homeless patients were now offered immediate and urgent appointments.
- Alerts were now added to the medical records of patients with a mental health diagnosis, so staff could offer quieter appointment times.
We rated population group working age people, as requires improvement because:
- The practice had a low cancer detection rate resulting from two week wait referrals.
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.
- Ensure the most recent rating is displayed conspicuously and legibly at each location delivering a regulated service and on their website
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
- Improve systems to identify and support carers.
- Implement a programme of two cycle audit.Consider how to meet the needs of patients with a hearing impairment, such as a hearing loop.
- Develop a practice leaflet to inform patients about the practice and services available to them.
- Improve systems for the reporting of incidents to nclude use of clinical commissioning group monitored systems.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.
Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of General Practice