13 December 2024
During a routine inspection
We carried out an announced comprehensive inspection at Dr Irlam & Partners (Central Surgery) on 13 December 2023. Overall the practice is rated as Requires Improvement.
Safe – requires improvement
Effective - good
Caring - good
Responsive - requires improvement
Well-led - good
Why we carried out this inspection
We carried out this inspection in line with our inspection priorities.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A short site visit.
Our findings
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 found that:
- Some patients’ care needs were not always reviewed and monitored in line with current legislation and standards.
- Safety alerts were not consistently discussed with patients as recommended.
- Staff had received appropriate training and there were effective health and safety risk assessments.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients could not always access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
We found 1 breach of regulations. The provider must:
- Improve the documented approach to the management of test results.
- Ensure that all patients received effective treatment and medicine reviews.
- Improve the system to respond to safety alerts from a variety of sources, including The Medicines and Healthcare products Regulatory Agency, (MHRA), and Central Alerting System, (CAS).
The provider should:
- Continue to take action to ensure the safe management of the documents inbox.
- Continue with efforts to improve the uptake of cervical screening.
- Progress work with the installation of a new telephony system to improve patient satisfaction relating to access results across all 4 indicators in the National GP Patient Survey.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care