The Care Quality Commission
  • Doctor
  • GP practice

Archived: John Pounds Surgery

Overall: Good read more about inspection ratings

3 Aylward Street, Portsmouth, Hampshire, PO1 3DU (023) 9281 2033

Provided and run by:
Lake Road Practice

All Inspections

05/11/2019

During a routine inspection

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

During a routine inspection

This practice is rated as Requires Improvement overall. (Previous rating September 2016 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at John Pound Surgery on 10 October 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice had purchased a new telephony system, due to be implemented in November 2018. The new system would allow patients who were waiting in a queue to opt for a call back when they were near the front of the queue, rather than waiting on the phone.
  • The practice had recently recruited additional staff members including two administrators and a paramedic. The pharmacist who had commenced employment at the practice in January 2018, working three days a week, provided a monthly face to face medicines review clinic at the practice.
  • Storage of medicines requiring refrigeration required improvement.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

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:

  • Develop and demonstrate a system to review test results received on GP non-working days.
  • Continue to develop the system to monitor actions taken, following safety alerts.
  • Continue to identify patients who are also carers.
  • Review arrangements for gathering patient feedback, including developing a patient participation group (PPG).

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

29 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at John Pounds Surgery on 29 September 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.
  • 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 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. The practice was working towards becoming a Dementia friendly practice. All staff had received training on Dementia awareness and they were in the process of changing signage and floor coverings in the building. They had consulted with the patient participation group and dementia care organisations on this work.
  • 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 practice had a three year strategic plan and performance was monitored at regular intervals.

The areas where the provider should make improvement are:

  • Continue to identify patients who are also carers.

  • Continue to encourage patients to take part in national screening programmes.

  • Review arrangements to ensure that staff recruitment files always contain all necessary information.

  • Ensure that prescriptions used in printers are always logged and checked for security purposes.

  • Ensure that there is a system to identify the expiry dates of emergency equipment.

  • Ensure policies and procedures are always up to date.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice