You are here

Archived: Pond Tail Surgery Good

The provider of this service changed - see new profile

Inspection Summary


Overall summary & rating

Good

Updated 12 September 2019

We carried out an announced focused inspection at Pond Tail Surgery on 6 August 2019 as part of our inspection programme.

At the last inspection in June 2018 we rated the practice as requires improvement for providing safe services because:

  • The practice did not always have reliable or effective systems to make sure that patients prescribed high risk medicines had regular and appropriate health monitoring and clinical review.
  • Systems and processes were not always in place to monitor and follow up on concerns for patients at risk, including children who were not brought to their appointments.
  • Safety alerts were not always documented, discussed and lessons learnt as a result.

We also found areas where the provider should make improvements:

  • Strengthen the guidance provided for staff to include identification of symptoms for potentially seriously ill patients, such as sepsis.
  • Continue to strengthen the systems used to record learning and share lessons, identified themes and action taken to improve safety in the practice as a result of significant events and complaints.
  • Ensure all staff are aware of the practice vision and future planning in relation to their role, and that improvements and innovation within the practice are communicated to all staff.
  • Review the arrangements in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • Continue to monitor and take action where appropriate for areas with high exception reporting on Quality Outcomes Framework.
  • Strengthen the programme of clinical audit and quality improvement activity, including to routinely review the effectiveness and appropriateness of the care provided.

We based our judgement of the quality of care at this service is 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.

Overall the practice continues to be rated as good and is now rated good for providing safe services.

Details of our findings

At this inspection we found:

  • There was a process for monitoring patients’ health in relation to the use of medicines, including high risk medicines. We reviewed a sample of patients prescribed such medicines and saw their health was being monitored appropriately, prior to prescribing.
  • The practice had processes in place to make sure vulnerable patients were monitored, and appropriate actions were completed as a result of any concerns.
  • There were processes to identify, understand, monitor and address current and future risks including risks to patient safety. The practice fully recorded, investigated and acted on safety alerts. Actions were taken to improve safety and lessons were learned.
  • The practice had resolved concerns relating to the guidance available to staff. Additional training was available to staff for identifying symptoms of serious infections.
  • The practice demonstrated that significant events and complaints were thoroughly recorded, investigated and acted upon. All identified themes, lessons and action taken to improve safety in the practice was shared with all staff.
  • Communication within the practice had improved and staff we spoke with were happy with the methods used to keep them up to date.
  • There were arrangements in place to cover staff absences and busy periods.
  • We found areas of high exception reporting and a lack of evidence to demonstrate quality improvement activity. The practice was experiencing staffing challenges which had impacted on their performance monitoring and improvement activity, including clinical audit.

The areas where the provider should make improvements are:

  • Continue to monitor and take action where appropriate for areas with high exception reporting on Quality Outcomes Framework.
  • Strengthen the programme of clinical audit and quality improvement activity, including to routinely review the effectiveness and appropriateness of the care provided.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

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

Inspection areas

Safe

Good

Effective

Good

Caring

Good

Responsive

Good

Well-led

Good
Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good