Archived: Mirfield Surgery - Sahay

We carried out an announced comprehensive inspection at Mirfield Surgery - Sahay on 21 November 2016 as part of our inspection programme. We rated the practice good overall.

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 and well-led.

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 and good for population groups; except people experiencing poor mental health (including people with dementia) population group which was rated as requires improvement due to clinical outcomes which were below local and national averages.

We found that:

• Patients received effective care and treatment that met their needs. The practice operated a programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
• The practice demonstrated awareness of their Quality Outcomes Framework (QOF) performance, and developed actions plans to improve areas where performance was below local and national averages.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care. Completed Care Quality Commission (CQC) comment cards as well as feedback placed on NHS Choices website were positive about how patients were treated.
• The practice responded to less positive patient satisfaction and developed an action plan to improve patient satisfaction. For example, the practice reintroduced extended hours, installed new phone lines and at the time of our inspection were in the final stages of arranging a dedicated call room away from the main reception area where call handlers would manage the phone lines.
• The practice responded to the influx of patients following the closure of neighbouring practices and organised and delivered services to meet increased demands and patients’ needs. Patients could access care and treatment in a timely way.
• The culture of the practice and the way it was led and managed drove the delivery and improvement of high-quality, person-centred care. For example, the management team demonstrated strong leadership skills; encouraged a learning culture and operated processes which enables staff to raise concerns without fear of retribution.
• There were clear responsibilities, roles and systems of accountability to support good governance and management. The practice operated a process for ensuring policies and procedures were reviewed and updated in line with local and national guidance updates.
• There were clear and effective processes for managing clinical and environmental risks. For example, fire as well as health and safety risk assessments were carried out; yearly infection control audits were carried out and the practice had arrangements to enable timely response in the event of a medical emergency.

Whilst we found no breaches of regulations, the provider should:

• Ensure actions to improve QOF performance in clinical areas such as people experiencing poor mental health including people with dementia is embedded.
• Continue taking action to improve the uptake of national screening programmes and the number of two week wait (TWW) referrals.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care