Background to this inspection
Updated
30 December 2019
John Pounds Surgery is located at 3 Aylward Street, Portsmouth, Hampshire PO1 3DU, in the docklands area of Portsmouth. It provides personal medical services to approximately 4,300 patients. The practice’s registered provider is Lake Road Practice.
John Pounds Surgery holds an Alternative Provider Medical Services contract and its services are commissioned by Portsmouth Clinical Commissioning Group. The practice is registered to provider the following regulated activities; treatment of disease, disorder or injury, surgical procedures, family planning, maternity and midwifery services and diagnostic and screening procedures.
The practice population is in the third most deprived decile for deprivation, in a score of one to ten. Its population has a higher proportion of unemployed than the national or local average, and a slightly lower life expectancy.
The practice list is managed by two GP partners, one non-clinical managing partner/practice manager, one salaried GP and a team of practice nurses, healthcare assistants, receptionists, managers and administration staff. The provider has another location nearby, and most staff, including all clinicians, work across both sites.
The practice is open between 8am and 6.30pm Monday to Friday. Appointments are available between 8.30am and 6pm. Extended hours appointments are offered by this practice on Saturday mornings at the provider’s other location.
More information in relation to the practice can be found on their website:
www.johnpoundssurgery.nhs.uk
Updated
30 December 2019
We previously carried out an announced comprehensive inspection at John Pounds Surgery on 10 October 2018 as part of our inspection programme. The practice was rated as requires improvement for effective and well-led, and for three population groups; people with long term conditions, families, children and young people and working age people. This meant the practice was rated requires improvement overall. We issued a requirement notice for Regulation 17: Good governance.
This inspection on 5 November 2019 was an announced comprehensive inspection to follow up on the breach of regulation and as part of our inspection schedule where services rated as requires improvement are subject to re-inspection within 12 months.
This inspection looked at the following key questions:
- Are services safe?
- Are services effective?
- Are services caring?
- Are services responsive?
- Are services well-led?
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 but we have continued to rate the practice as requires improvement for providing well-led services.
We rated the practice as requires improvement for providing well-led services because:
- Governance systems had not identified where there were gaps in assurance or areas for improvement.
- Systems to promote learning from complaints and significant events were not embedded.
We rated the practice as good for providing safe, effective, caring and responsive services because:
- The practice had systems, practices and processes to manage risks, manage medicines and to keep people safe from abuse.
- Patient needs were assessed and their care and treatment was based on evidence-based guidance.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
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.
The areas where the provider should make improvements are:
- Make complaint information for patients more readily available and include information relating to the Parliamentary Health Service Ombudsman.
- Continue to monitor patient outcome indicators, including cervical screening uptake and exception reporting.
- The outcome column in the safety alert spreadsheet did not include a summary of the specific actions taken against each alert which would provide a clear audit trail.
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