This practice is rated as good overall. Population groups are all rated as good except for
people whose circumstances make them vulnerable,
which was rated as outstanding.
We carried out an announced comprehensive inspection at Pinfold Lane Surgery on 21 January 2020. The practice had been formed under a new provider Health Care First Partnership in 2017 arising from a merger between two previously established practices, Ferrybridge Medical Centre and Dr Bance and Partners. The new practice has a continuing regulatory history with the Care Quality Commission from these previous providers. At their last inspections Ferrybridge Medical Centre was rated outstanding overall, and Dr Bance and Partners was rated as good overall.
We based our judgement on 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.
- Information from the provider, patients, the public and other organisations.
We found that:
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. Learning from incidents was shared with others to prevent recurrence.
- The practice had developed a medicines team which had improved prescribing and medication performance which as a consequence had increased clinical capacity.
- As a provider of primary services at scale, the practice had developed a detailed governance system and introduced procedures and processes to support this. This included the monitoring and reporting of performance.
- Quality improvement activity was embedded within the practice. This included clinical audit, and measures to improve governance, oversight and organisational management.
- The new provider and the management team had a good understanding of the challenges facing the practice and had put in place measures to resolve and tackle these.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.
- The practice had established a patient contact centre which included patient call back and triage to manage demand and access to services. This centre dealt with approximately 4,000 contacts per week.
- Members of clinical and non-clinical teams reported being well supported in their roles. The practice had appointed a staff liaison manager to lead on improved communication and staff integration issues.
- Performance in relation to cervical screening was below the national target. However, the practice had identified measures to improve this.
- The practice had developed a nurse-led home visiting service which provided timely assessments and services to support the needs of housebound patients.
- The practice had identified groups in need of additional support and actively supported carers and veterans from within their patient population.
- Members of the senior management and leadership team worked collaboratively with other services within the local health and care community.
We saw the following areas of outstanding practice including:
- The practice had developed a dedicated team to support those with a learning disability or learning difficulty. This service provided additional personalised patient contact and care, and offered patients greater flexibility and adjustments to meet their specific needs.
- The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care.
The areas where the provider should make improvements are:
- Introduce a system to ensure the accurate recording of dispensed controlled drugs upon collection or within 24 hours.
- Record the delivery of prescription stationery into the relevant practice branch surgery in accordance with national guidance.
- Implement and embed a system to record the medicines delivery driver’s signature upon receipt of medicines for dispatch.
- Continue to reduce to summarising backlog at the practice.
- Improve the take-up of cervical screening amongst target groups.
Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Rosie Benneyworth BM BS MDedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care