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Inspection carried out on 31/10/2019

During a routine inspection

Following our annual regulatory review of the information available to us, we inspected this service on 31 October 2019. The service was last inspected in February 2016. It was rated as good for each of the five key questions and rated good overall. This inspection looked at the following key questions; was the service providing effective and well led services for the registered patient population. We decided not to inspect whether the practice was providing safe, caring or responsive services as there was no information from the annual regulatory review which indicated this was necessary.

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 all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Governance systems were robust and regularly reviewed.
  • The practice was engaged in local initiatives and worked alongside partners in the local healthcare system.

We found no breaches of regulations. However, the areas where the practice should make improvement are:

  • Continue to implement actions with a view to improving uptake for the cervical screening programme.
  • Continue to monitor exception reporting data that was outside of the expected range.
  • Continue to support the actions designed to implement the Patient Participation Group.

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 carried out on 23 February 2016

During a routine inspection

We carried out an announced comprehensive inspection at The Royal Well Surgery on 23 February 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • 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.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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. (Duty of Candour is a legal duty to ensure providers are open and transparent with patients who use services. It also sets out specific requirements providers must follow when things go wrong with care and treatment, including informing patients about the incident, providing reasonable support, providing truthful information and an apology when things go wrong).

The areas where the provider should make improvement are:

  • Review how the practice identifies carers in order to increase the numbers of patients who may require carer support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice