We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions: effective, responsive and well led.
The practice was first inspected in November 2013. This was an unrated inspection under the CQC’s previous inspection framework. At that inspection the practice was issued with compliance notices for Regulation 12 (cleanliness and infection control) as there was no effective inspection control system in place, and Regulation 19 (complaints) as the practice did not have an effective complaints procedure in place. A Follow up inspection took place in May 2014 where the practice was found to be meeting the standards for Regulation 19. At a follow up inspection in September 2014 the practice was found to be meeting the requirements for Regulation 12.
The first rated inspection took place on 7 August 2016. The practice was rated good for all key questions and population groups and good overall.
At this inspection (4 March 2020), 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 good overall.
We rated the practice as good for providing an effective, responsive and well-led service because:
- The practice had not met national targets for the cervical cancer screening programme, however measures had been put in place to improve the results of the programme.
- The practice had not met World Health Organisation (WHO) targets for the childhood immunisation programme but was working on a number of steps to improve this.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Take action to improve the uptake for the childhood immunisation programme.
- Take action to improve the uptake for the cervical cancer screening programme.
- Consider recording exception rates for the Quality Outcome Framework (QOF).
- Consider ways to improve results from the national GP patient survey.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP