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Drs Pearce and Trenholm Good Also known as Springmead Surgery

Inspection Summary


Overall summary & rating

Good

Updated 7 May 2020

We carried out an announced focussed inspection at Drs Pearce and Trenholm on 5 March 2020 as part of our inspection programme, and as a follow up to our last inspection on 11 December 2018.

When we last inspected Drs Pearce and Trenholm on 11 December 2018 it was rated as Requires Improvement overall; Requires Improvement for providing safe, effective and well-led services and Good for providing caring and responsive services. All the population groups were rated as Good other than those for people with long-term conditions, working age people (including those recently retired and students), and people experiencing poor mental health (including people with dementia) which were rated as Requires Improvement.

A requirement notice was issued to ensure that care and treatment was provided in a safe way to patients, effective systems and processes were established to ensure good governance in accordance with the fundamental standards of care and that the provider ensures that changes to its registration details are notified to the CQC.

This inspection focused on the following key questions:

  • Are services safe?
  • Are services effective?
  • Are services well led?

Because of the assurance received from our last inspection, we carried forward the ratings for the following key questions:

  • Are services caring? (Good)
  • Are services responsive? (Good)

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 provided the practice with Care Quality Commission feedback cards prior to the inspection and we received eight completed cards. Patients were generally positive about the practice staff, their experiences, and the care and treatment they received.

We have rated Drs Pearce and Trentholm as Good overall.

We have rated Drs Pearce and Trenholm as Requires Improvement for providing effective services and Requires Improvement for the two population groups which includes people with long term conditions and People experiencing poor mental health (including people with dementia) because:

  • Quality and Outcomes Framework (QoF) clinical indicators were below local and national averages for people with long-term conditions, and people experiencing poor mental health (including people with dementia). Exception reporting was also below local and national averages for these indicators.
  • The practice participated in national health priority schemes and initiatives to improve the population’s health. However, there were variations in the uptake of national screening programmes. The practice demonstrated awareness of this and were taking some action to improve the uptake of cervical screening.

We have rated Drs Pearce and Trenholm as Good for providing safe and well led services, and Good for all population groups other than the two population groups which includes people with long term conditions and people experiencing poor mental health (including people with dementia) because:

  • At this inspection, we found all the areas of concern from the last inspection had been addressed and improved.
  • We found the practice had successfully coped with a significant change and re-organisation of the management team.
  • 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 had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
  • Staff had the skills, knowledge and experience to deliver effective care, support and treatment.
  • Staff worked together and with other organisations to deliver effective care and treatment.
  • There was compassionate, inclusive and effective leadership at all levels. This included working with and supporting the practice Patient Participation group (PPG).
  • The practice had a clear vision and set of values that prioritised quality and sustainability.
  • The practice had a culture that drove high quality sustainable care.
  • There were clear responsibilities, roles and systems of accountability to support good governance and management.
  • There were processes for managing risks, issues and performance.

Although we did not find any beaches of regulation at this inspection, we did see some areas where the provider should make improvements. These are:

  • Continue monitoring the uptake of cervical screening in line with national guidance.
  • Continue monitoring exception reporting and associated performance data to support patients with long term conditions and those experiencing poor mental health (including people with dementia).
  • Continue implementing the changes identified within the practice business plan.

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

Inspection areas

Safe

Good

Effective

Requires improvement

Caring

Good

Responsive

Good

Well-led

Good
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Good