16 Oct 2019
During an inspection looking at part of the service
We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:
Are services Effective?
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.
At our previous inspection on 16 April 2016, we found some areas where the practice should make improvements:
- Ensure that any action from the legionella assessment that is due to be carried out in July 2016 are completed.
- Ensure all non-clinical staff undertake basic life support training.
- Ensure staff appraisals are undertaken.
At this inspection we found:
- The practice had undertaken a legionella assessment in May 2019, which identified some areas in need of action. During our inspection we found the practice had carried out most works with the exception of: starting monthly water temperature monitoring; and legionella awareness training. At the time of our inspection the practice had scheduled the necessary training for November 2019 and thereafter was to commence monthly water temperature monitoring.
- All non-clinical staff had received training in basic life support.
- All staff who needed one had received an appraisal within the last 12 months.
- Patients received effective care and treatment that met their needs.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
The areas where the provider should make improvements are:
- Continue to work to complete all actions identified in its recent Legionella risk assessment report.
- Review and continue to work to improve levels of uptake for childhood immunisations and cervical screening for the benefit of those population groups.
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