We carried out an announced comprehensive inspection at Wyncroft Surgery on 16 November 2022. Overall, the practice is rated as good. This is the practices first inspection since registering on 21 May 2021.
The ratings for each key question
Safe - Good
Effective – Good
Caring – Good
Responsive - Good
Well-led – Good
Why we carried out this inspection
This inspection focused on:
- Safe, effective, caring, responsive and well-led services
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
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
- Staff questionnaires
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 this practice as Good overall.
We found that:
- We found the monitoring of medicines and safety alerts were carried out in line with national guidance.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- The practice had carried out a range of environmental risk assessments to ensure the safety of their staff and patients.
- The infection control audit was 5 months overdue. The practice was aware and had scheduled it for the next time to learn session on 29 November 2022.
- The practice regularly checked their emergency medicines however we found that two of the recommended emergency medicines were not stocked at the practice. Following the inspection, the practice had ordered the relevant medicines.
- Medication reviews we reviewed were documented to a high standard to ensure patients were aware of potential risks.
- The practice had safeguarding systems in place to ensure patients and staff were kept safe.
- The practice has a system in place to identify patients that were not for resuscitation and details were documented on the clinical system for external agencies to view. However, we found there was only one patient with the formal DNACPR form noted in their records.
- Although the practice had completed audits to drive quality improvement, there was no two cycle audits which could evidence that change implemented had improved the quality of the service.
- The practice had identified a high number of carers to offer support to while they were caring for relatives.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The National patient survey data, published July 2022, showed that the practice was in line with the national average for caring and responsive services.
- Staff told us that additional support with concerns raised would be welcomed.
- 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.
Whilst we found no breaches of regulations, the provider should:
- Continue to undertake quality improvement audits.
- Strengthen systems to document DNACPR on clinical systems
- Continue to monitor infection prevention and control concerns.
- Strengthen systems to review emergency medicines.
- Work to improve staff morale within the practice.
- Continue to improve the uptake of breast cancer screening
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services