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Review carried out on 7 October 2021

During a monthly review of our data

We carried out a review of the data available to us about The Pump House Surgery on 7 October 2021. 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.

Review carried out on 21 December 2019

During an annual regulatory review

We reviewed the information available to us about The Pump House Surgery on 21 December 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 11 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

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.

  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns; however the lessons identified and actions to be taken were not sufficiently documented to ensure the improvements had ben actioned.
  • 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 practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had identified a low number of patients who were carers.
  • There was a system in place for infection control but issues identified as areas for improvement had not been actioned. There had been no infection control audit as required by guidance.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice had good facilities and was well equipped to treat patients and meet their 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice