The Care Quality Commission
  • Doctor
  • GP practice

Pump Lane Surgery Also known as The Surgery

Overall: Good read more about inspection ratings

13 Pump Lane, Rainham, Gillingham, ME8 7AA (01634) 231856

Provided and run by:
Dr Ayodeji Durowoju

Important: The provider of this service changed. See old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Pump Lane 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 Pump Lane Surgery, you can give feedback on this service.

01 November 2022

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Pump Lane Surgery on 11 February 2022. The overall rating for the practice was Requires Improvement.

After our inspection in February 2022, the provider wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

We carried out an announced focused follow up inspection on 1 November 2022 to follow up the breaches of regulation found in our previous inspection in February 2022. Overall, the practice is rated as Good.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services well-led? – Good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Pump Lane Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from the previous inspection.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was in line with all data protection and information governance requirements.

This included:

  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider,
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

Our findings

Our judgement of the quality of care at this service is based 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 found that:

  • The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse.
  • Recruitment checks were carried out in accordance with regulations.
  • 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.
  • Appropriate standards of cleanliness and hygiene were met.
  • There were adequate systems to assess, monitor and manage risks to patient safety.
  • Staff had the skills, knowledge and experience to carry out their roles.
  • The practice learned and made improvements when things went wrong.
  • Patients’ needs were assessed, and care as well as treatment were delivered in line with current legislation, standards and evidence-based guidance.
  • Published results showed the childhood immunisation uptake rates for the vaccines given were above the 90% minimum target.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
  • The practice involved the public, staff and external partners to sustain high quality and sustainable care.
  • Systems for managing safety alerts were effective.
  • The practice had a programme of targeted quality improvement and used information about care and treatment to make improvements.

The areas where the provider should make improvements are:

  • Continue to implement and monitor the outcome of plans to improve performance relating to antibiotic prescribing.
  • Continue to review coding for patients who require regular monitoring.
  • Ensure conversations regarding the risks of certain medicatons have been appropriately recorded.
  • Review processes to ensure plans for second cycle audits are recorded.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

11 February 2022

During a routine inspection

This practice is rated as Requires Improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced inspection at Pump Lane Surgery on 11 February 2022 under Section 60 of the Health and Social Care Act 2008, as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The full comprehensive report can be found by selecting the ‘all reports’ link for Pump Lane Surgery on our website at www.cqc.org.uk.

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Kent and Medway. To understand the experience of GP Providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Requesting evidence from the provider
  • A short site visit

Our findings

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 Requires Improvement overall.

We found that:

  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • The practice respected patients’ privacy and dignity.
  • There were systems and processes for learning and continuous improvement.
  • Published results showed the childhood immunisation uptake rates for the vaccines given were above the 90% minimum target.
  • Patient feedback about the practice was positive and results from the national GP patient survey were in line with local and national averages.
  • Staff were suitably trained in emergency procedures.
  • Risks to patients, staff and visitors were not always assessed, monitored and managed in an effective manner.
  • Staff had the skills, knowledge and experience to carry out their roles. However, not all staff were up to date with essential training.
  • The arrangements for managing medicines did not always help keep patients safe.
  • The practice’s computer system did not alert staff of all family and other household members of vulnerable children or adults.
  • Systems for managing safety alerts were not always effective.
  • Patients’ needs were not always assessed, and care as well as treatment were not always delivered in line with current legislation, standards and evidence-based guidance.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

The areas where the provider should make improvements are:

  • Continue to monitor the emergency medicines and equipment held at the practice to ensure sufficient stock.
  • Continue to implement and monitor the outcome of plans to improve performance relating to antibiotic prescribing.
  • Continue to assess, monitor and improve actions highlighted in the infection prevention and control audit.
  • Continue to ensure patients on the palliative care list have their palliative care needs reviewed and recorded.

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