We have rated this practice as inadequate overall.
https://www.cqc.org.uk/location/1-537878483/inspection-summary
We rated the practice as inadequate for providing safe services because:
- The provider did not have clear systems and processes to keep patients safe.
- The provider did not have reliable systems and processes to keep patients safeguarded from abuse.
- The provider did not have a safe system in place to manage safeguarding training for staff.
- The provider did not have a safe system in place to monitor and manage recruitment, including disclosure and barring checks (DBS).
- The provider did not have appropriate systems in place to safely manage high-risk medicines and medicines that require additional monitoring.
- The provider did not have a safe effective system in place to manage patient safety alerts.
- The provider did not operate a safe system regarding staff immunisations and certified immunity.
- The provider did not have failsafe processes regarding two-week wait referrals and cervical screening.
- The provider did not have a safe effective system in place to manage significant events.
We rated the practice as requires improvement for providing effective services because:
- Clinical care was not delivered consistently in line with national guidance.
- There was limited recent clinical quality improvement activity.
- There was limited monitoring of the outcomes of care and treatment.
- The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
- Some performance data was significantly below local and national averages.
We rated the practice as good for providing caring services because:
- GP Patient Survey results were in line with local and national averages.
- There was evidence the provider had taken action to improve patient experience at the practice in response to feedback from the patient participation group.
- There was evidence to show how the practice carried out patient surveys and patient feedback exercises.
We rated the practice as requires improvement for providing responsive services because:
- The provider did not have a safe effective system in place to manage patient complaints.
We rated the practice as inadequate for providing well-led services because:
- Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
- The overall governance arrangements were ineffective.
- The practice did not have clear and effective processes for managing risks, issues and performance.
- The practice did not always act on appropriate and accurate information.
- We saw limited recent evidence of systems and processes for learning, continuous improvement and innovation
The areas where the provider must make improvements are:
- Ensure that care and treatment is provided in a safe way.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The provider should:
- Continue to take action to improve childhood immunisation and cervical screening achievement rates.
- Continue to regularly review practice polices to include the most recent appropriate information available.