This practice is rated as Good overall. This was the first inspection of Barrow and Millom PCN area since the service was registered in July 2020.
The key questions 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 Barrow and Millom PCN Area on 8 September 2022 as part of our inspection programme as the service had not been inspected or rated.
At this inspection we found:
- Leaders prepared well and engaged positively in the inspection process. They responded quickly to inspection findings in response to initial feedback with a “lessons learned” document and evidence of actions taken.
- The provider had established clear responsibilities, roles and systems of accountability to support good governance and management and there was oversight of quality and performance, finance, strategy and risk through a board of directors.
- Clinical audits were routinely undertaken for all staff involved in clinical activity that was overseen by the medical director.
- There was a strong focus on continuous learning and improvement at all levels of the organisation. Leaders were clear on areas that required improvement activity and were working to address these.
- Staff involved and treated patients with compassion, kindness, dignity and respect. Patient feedback regarding clinical staff and service satisfaction levels were very positive. There were systems in place to respond to concerns and complaints.
The areas where the provider should make improvements are:
- Obtain outstanding evidence and maintain up-to-date records of all mandatory training modules for staff working in the extended access service.
- Embed into practice the new induction programmes and three stage site visit audit process to maintain assurance that premises used by the extended access services are safe and appropriately equipped.
- Review and update the concerns and incident logs to ensure sufficient information is documented to provide a clear audit trail of actions taken.
- Develop a policy on the Accessible Information Standards.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services