We carried out an announced inspection at Pinfold Medical on 20 and 29 September 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring – Good
Responsive - Good
Well-led - Good
Following our previous inspection on 3 and 6 March 2020, the practice was rated Requires Improvement overall. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Pinfold Medical on our website at www.cqc.org.uk
Why we carried out this inspection/review
This was a focused inspection to follow up on:
- The safe, effective and well-led key questions
- Any breaches of regulations or ‘shoulds’ identified at our last inspection.
Because of the assurance received from our review of information we carried forward the ratings for the following key questions: Caring and Responsive.
How we carried out the inspection/review
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- 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 have rated the practice as Good overall with the exception of People experiencing poor mental health (including people with dementia) which we rated as Requires Improvement.
We found that:
- There were clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
- Patients received effective care and treatment that met their needs.
- Staff had the skills, knowledge and experience to deliver effective care, support and treatment. There was clinical oversight and effective systems for quality improvement.
- Although the practice remained below the threshold for long term condition reviews and cervical screening rates, they were able to evidence that an action plan was underway to improve outcomes with progress monitoring in place.
- Mental health indicators were below local and national averages which had declined further since our last inspection and action taken had not yet demonstrated improved outcomes.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could 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.
- Although our clinical searches identified some issues with high risk medicine management, these issues were not systemic, and the provider demonstrated they had the capacity and capability to address them.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. There were systems and processes in place for the recruitment of staff in accordance with the regulations.
- We found health and safety, fire safety risk assessment, security risk and infection control assessments had been completed at the practice premises.
Whilst we found no breaches of regulations, the provider should:
- Continue to strengthen processes for the reviewing high risk medicine and actioning of safety alerts.
- Continue to work to improve the quality of care and treatment for people experiencing poor mental health.
- Continue with steps to review those patients with long term conditions.
- Continue to increase the uptake for cervical, breast and bowel screening.
- Continue with steps to engage with a patient participation group.
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