We carried out a review of the data available to us about The Pump House Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about The Pump House Surgery, you can give feedback on this service.
We carried out an announced comprehensive inspection at Pump House Surgery. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Incidents were investigated and learning had been identified but there was a lack of evidence to demonstrate that this learning had been cascaded to relevant staff.
There were no practice specific standard operating procedures in place for the dispensary service offered by the practice; however medicine errors and near misses were being reported, analysed and lessons learnt embedded into practice.
We saw that national patient safety and medicine alerts were received, reviewed and actioned appropriately. However some staff were not aware of a recent alert and the documentation of initialling the alert once read; several alerts had one signature.
There was a bespoke standard operating procedure in place for the dispensary.
Infection control audits were undertaken and actions identified dealt with in a timely way.
Families who suffered bereavement received personalised follow up care from the GP that had most contact with the family in the last weeks of care.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
There was some evidence of quality improvement activity including clinical audit. However the conclusions of the audits did not identify where improvements could be made.
Patients were supported, treated with dignity and respect. Patients were encouraged and supported to be involved as partners in their care.
Patients said they were able to access the right care at the right time; appointments were managed to take account of patient’s needs, including those with urgent needs.
The areas where the provider should make improvement are:
Ensure that the learning from the investigation of safety incidents and complaints is shared with relevant staff and documented.
Identify a lead staff member to oversee infection control.
Improve the identification of patients who are carers.
Chief Inspector of General Practice