We carried out an announced comprehensive inspection at Pelsall Village Surgery on 16 October 2019 as part of our inspection programme.
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:
- Patients received effective care and treatment that met their needs and was planned and delivered according to evidence-based guidelines.
- Staff had the skills, knowledge and experience to deliver effective care, support and treatment and worked together and with other organisations to deliver effective care and treatment.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients were highly satisfied with the with the service they received from the practice. Staff felt valued and supported in their work. There was an effective relationship between the practice and the patient participation group.
- The practice supported the local community through fund raising events, and links with the local primary school.
- The practice had reviewed and re-organised the way in which services were delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
- The culture of the practice and the way it was led and managed drove the delivery and improvement of high-quality, person-centred care.
- There was a focus on continuous learning and improvement at all levels of the organisation. For example: the practice encouraged and supported the staff to develop their skills and knowledge, for example staff attending post graduate degree courses.
Whilst we found no breaches of regulations, the provider should:
- Update the safeguarding policy to include modern slavery, sexual exploitation and radicalisation.
- Provide all staff with PREVENT training.
- Obtain assurances from the locum agency that the recruitment checks had been carried out in accordance with regulations.
- Further develop the COSHH risk assessment and log of products and assessments for specific risks.
- Obtain assurances from the landlord regarding the fire alarm system and legionella risk assessment.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of General Practice