Updated 7 November 2024
Date of assessment: 3 to 31 October 2024.
We carried out this assessment in response to concerns and risk we identified through our ongoing monitoring of the service.
We found a breach of regulation in relation to governance.
The practice now did not have:
• A culture based on openness and honesty in which learning from incidents and significant events were identified as used fully to improve the service
• A strong focus on continuous learning, innovation and improvement.
• Effective systems in place to help protect people from harm, including safeguarding; assessing and responding to risks to people’s safety; and assessing, reviewing and monitoring patients’ health.
• Systems to show staff provided safe and effective care that was in line with up-to-date guidance, legislation and good practice
• Effective strategic leadership and oversight of the running of the practice.
However:
• People could give feedback about their care and treatment.
• The practice worked with the Patient Participation Group (PPG) when making changes to the service.
• People were given information to help them to live healthier lives.
• Staff treated people as individuals and put them at the centre of their care.
• People could usually access care and treatment when they needed it.
• The practice registered new patients, processed letters and test results coming into the practice and sent referrals to other services in a timely manner.
• Staff were positive about the leadership of the practice and there was a shared vision for the service. However, staff had not been involved in planning the future of the practice.
In instances where the Care Quality Commission (CQC) have decided to take enforcement action, we will publish this information on our website after any processes have been concluded.