The Care Quality Commission
  • Doctor
  • GP practice

Pallion Family Practice

Overall: Good read more about inspection ratings

Pallion Health Centre, Sunderland, Tyne and Wear, SR4 7XF (0191) 567 4673

Provided and run by:
Pallion Family Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Pallion Family Practice 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 Pallion Family Practice, you can give feedback on this service.

24 December 2019

During an annual regulatory review

We reviewed the information available to us about Pallion Family Practice on 24 December 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

7 November 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pallion Family Practice on 20 September 2016. The overall rating for the practice was good, although the practice was rated as requires improvement for providing well-led services. We issued a requirement notice with respect to Regulation 17 on Good Governance because we found that processes were not in place to assess, monitor and improve the quality of service provided in carrying out the regulated activities for which the practice is registered. The full comprehensive report for the September 2016 inspection can be found by selecting the ‘all reports’ link for Pallion Family Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 7 November 2017 to review in detail the actions taken by the practice to improve the quality of care. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

The practice is now rated as good for providing well-led services, and overall the practice is rated as good.

Our key findings at this inspection were as follows:

  • The practice had implemented an action plan to address most of the issues identified during the previous inspection.
  • Appropriate arrangements were now in place to record and investigate significant events.
  • Appropriate arrangements were now in place to ensure all relevant staff were aware of patient safety alerts.
  • The practice had improved their approach to clinical audit; however, further improvements should still be made.
  • Appropriate arrangements were now in place to record and monitor staff training.

At our previous inspection on 20 September 2016, we also told the provider that they should make improvements in other areas that included recruitment checks, complaints and appointment management. We saw at this inspection that improvements had been made:

  • The practice had a process in place to ensure relevant recruitment checks were carried out and recorded. Records we checked confirmed that improvements had been made.
  • Appropriate arrangements were now in place to record verbal complaints. When the practice responded to complaints with a letter this now included advice on what to do if the complainant was unhappy with the practice’s response.
  • The practice had reviewed their appointment system to ensure its structure met the needs of the patient population. The patient participation group had supported the changes made and we saw that since changes had been made there had been a 14% reduction in the number of appointments where patients did not attend.

At this inspection, we found that there were some areas of practice where the provider still needed to make improvements. We also found that the practice’s registration with CQC was not up to date.

Therefore the provider should:

  • Complete the process for the registration of the partnership with the Care Quality Commission.
  • Continue to improve the arrangements for clinical audit. Clinical audit should be clearly linked to patient outcomes, monitored for effectiveness and comprise of two cycles to monitor improvements to patient outcomes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

20 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pallion Family Practice on 20 September 2016. Overall the practice is rated as good.

Our key findings were as follows:

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • There was limited use of systems to record and report safety concerns and incidents. Only those incidents which also involved other organisations or services were formally recorded.
  • Most 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. However, verbal complaints were not recorded and the practice did not always include appropriate information for patients in their complaints responses.
  • Results from the National GP Patient Survey, published in July 2016, showed that patients’ satisfaction with how they could access care and treatment was below local and national averages. However, most patients we spoke with on the day were able to get appointments when they needed them.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure in place and staff felt supported by management. The practice sought feedback from staff and patients, which they acted on.
  • Staff throughout the practice worked well together as a team.
  • There was a high level of staff satisfaction. Staff spoke highly of managers; several staff had worked at the practice for many years.
  • Staff were supported to develop their careers, and several were undertaking professional qualifications, however, the systems for recording and monitoring staff training were not effective.

The areas where the provider must make improvements are:

  • Establish systems and processes to assess, monitor and improve the quality and safety of services; including ensuring arrangements are in place to record and investigate all significant events, implement processes to ensure all relevant staff are aware of patient safety alerts and any subsequent action to be taken. Put plans in place to develop the clinical audit programme and ensure clinical audit cycles are completed. Ensure there are systems in place to record and monitor staff training.

In addition, the provider should:

  • Take steps to ensure that all relevant recruitment checks are carried out for all staff before they commence employment.
  • Improve arrangements for dealing with verbal complaints; take action to ensure that replies to complaints include advice on what to do if the complainant was unhappy with the practice’s response.
  • Continue to monitor capacity and demand to ensure the appointments structure meets the needs of the patient population.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice