This service is rated as good overall.
The key questions are rated as:
Are services safe? – Good
Are services effective? – Requires Improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
We carried out an announced comprehensive inspection at Kimberlow Hill Surgery as part of our inspection programme. This service was previously registered as a location of Wenlock Terrace Surgery and was inspected under that service name. The full comprehensive report on the previous inspections can be found by selecting the ‘all reports’ link for Wenlock Terrace Surgery on our website at .
The service is rated as good overall. We rated the key questions as good with the exception of the effective domain which we rated as requires improvement. Consequently, we rated all the population groups as requires improvement as the measures the practice had put in place for improvement were in infancy and not yet demonstrated in data.
Our key findings were as follows:
- The provider encouraged reporting of incidents.
- The practice had systems in place to manage risk so that safety incidents were less likely to happen.
- There was monitoring of the outcomes of care and treatment.
- Performance data in 2017/2018 was significantly below local and national averages, however recent data showed a marked improvement.
- There were arrangements in place to review the effectiveness and appropriateness of the care being provided.
- Arrangements for monitoring and reviewing prescribing helped ensure that patients were kept safe.
- Arrangements were in place to ensure that staff were working within the scope of their competency. Staff received appropriate support, training, professional development and appraisal as was necessary to carry out the duties they were employed to perform.
- During our inspection we saw that staff treated patients with compassion, kindness and respect.
- Arrangements for the identification of carers and offer of support were in place.
- Patients and staff told us that making an appointment to see a clinician was difficult, a new telephone system had been introduced in July 2019 to improve this.
- The practice had established a system for identifying, receiving, recording, handling and responding to complaints by patients.
- Governance arrangements were being operated effectively to ensure the delivery of care.
The areas where the provider should make improvements are:
Continue to monitor and improve care and treatment for patients as planned and provide regular reviews and assessment of needs in line with evidence-based guidance.
Improve the uptake of cervical cancer screening for eligible women.
Continue to monitor the effectiveness of the new telephone system in relation to improving access to appointments.