18 March 2019
During a routine inspection
This service is rated as Good overall.
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires Improvement
We carried out an announced comprehensive inspection at Improving Health Extended Primary Care Service on 18 March 2019 as part of our inspection programme.
At this inspection we found:
- The service did not have systems and processes in place to ensure adequate oversight of risk management activities associated with the host premises including fire and legionella.
- There was a lack of effective oversight of staff training and recruitment. Some recruitment information had not been retained and training had not been completed.
- There were good systems to identify and manage significant events.
- The service 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 people with compassion, kindness, dignity and respect.
- Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
The areas where the provider must make improvements as they are in breach of regulations 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:
- Review the service complaint policy.
- Continue with plans to hold and keep records of regular clinical meetings which include all clinical staff working at the service.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care