We carried out a review of the data available to us about Sovereign Practice 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 Sovereign Practice, you can give feedback on this service.
We carried out an announced comprehensive inspection at the Sovereign Practice on 26 April 2016. We found that the practice required improvement for the provision of effective services because breaches of regulation were identified. The full comprehensive report on the 26 April 2016 inspection can be found by selecting the ‘all reports’ link for Sovereign Practice on our website at www.cqc.org.uk.
This inspection was an announced focused inspection carried out on 15 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 26 April 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
The practice is now rated as good for providing effective services as well as good overall.
Our key findings were as follows:
Improved systems and processes had been implemented to ensure performance and patient outcomes were effectively monitored and audited.
Systems had been initiated to effectively manage and monitor role specific training requirements.
At the previous inspection in April 2016 we also told the provider that they should make improvements in relation to:
Ensuring that the system for recording significant event actions was improved. At this inspection we found that a new electronic recording form was available where detailed information was recorded. Significant events were a standing item on the agenda of practice meetings. Outcomes and learning points were discussed, reviewed and detailed in the minutes of meetings.
The identification of patients who are registered with them who are also carers. The practice had increased the percentage of patients on the register from 0.3% (54 patients) to 2% (257 patients). Identified carers for whom it was appropriate were referred to a local support organisation.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Sovereign Practice on 26 April 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 been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
Data showed patient outcomes were lower than the national average. Although some audits had been carried out, we saw limited evidence that audits were driving improvements to patient outcomes.
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. Improvements were made to the quality of care as a result of complaints and concerns.
Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with all patients being offered an appointment on 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.
The areas where the provider must make improvement are:
Ensure that a comprehensive programme of clinical audits and re-audits is implemented to improve patient outcomes.
Ensure that the recent improvement in QOF scores is proactively driven forward and solutions identified to continue improving in those performance areas.
Ensure that cleaning schedules include sufficient detail to be fully auditable.
Ensure that a system for managing and monitoring the need for role specific refresher training is introduced.
The areas where the provider should make improvements are:
Ensure that a robust and auditable system of recording actions and outcomes is implemented in relation to significant events.
Ensure that minutes of meetings incorporate a process for taking actions forward.
Ensure that additional activity is undertaken to identify and register those patients with caring responsibilities.
Chief Inspector of General Practice
We spoke with nine adult patients and two children on the day of the inspection visit. We also spoke with three of the GPs, the practice manager, four practice nurses, a telephonist and receptionist.
Patients told us that they felt well informed and involved in making decisions about their care and treatment. They said that all staff were approachable. Confidentiality was protected. Patients were happy with the care and treatment they received and valued the local services provided. However, some found that they experienced difficulties in getting an appointment on the day.
We looked at the processes that the practice had in place to ensure the patients were protected from abuse. We found that staff had received appropriate training on all safeguarding issues. Staff spoken with understood that any suspicion of abuse needed to be reported.
Staff told us that they had training and development opportunities and that they were well supported by the provider. They felt well qualified for their roles and responsibilities.
We found processes in place to review and monitor the quality of the service provided. Patient surveys were conducted with the results analysed. There was learning from the processes and the information was used to improve the service.