20 Sep 2018
During a routine inspection
This practice is rated as Good overall. (It has not previously been inspected)
The key questions at this inspection are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We carried out an announced comprehensive inspection at Sandringham Practice on 20 September 2018 as part of our inspection programme.
At this inspection we found:
- Published practice performance data generally pre-dates the date on which (17 October 2017) the new provider took over responsibility for running the practice. Accordingly, this has been reflected in our report. For example, for the data collection period 1 April 2016 – 31 March 2017 the practice had screened 68% of eligible patients for cervical cancer, which was below the national screening target of 80%. For the period 1 April 2017 – 31 March 2018 the practice showed us with its unpublished, unverified, data which showed that it had screened 81% of eligible patients.
- Clinical waste was appropriately stored, but the practice did not label bags. During our inspection the practice labelled the clinical waste bags currently in use and introduced an amended procedure to ensure that this would continue to be done.
- We saw no evidence of discrimination when making care and treatment decisions.
- The practice had 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 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.
- Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
The areas where the provider should make improvements are:
- Review the security arrangements for prescription computer paper.
- Review its patient participation group and work to hold regular meetings and encourage new members to join.
- Review and continue to work to improve uptake of its child immunisation programme for the benefit of that patient population.
- Review and continue to work to improve uptake of its cancer screening programmes for the benefit of that patient population
- Review and ensure that all outstanding actions identified in the Infection Prevention and Control audit and fire risk assessments are addressed.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.