We carried out an announced comprehensive inspection on 7 December 2017 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations

Are services well-led?

We found that in some areas this service was not providing well-led care in accordance with the relevant regulation

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The provider supplies private general practitioner services.

Dr Seth Rankin is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We reviewed six CQC patient comment cards all of which were exclusively positive about the service provided. The comment cards stated that staff were caring and considerate and appointments were easy and convenient to access.

Our key findings were:

• There was a system in place for acting on significant events though there was no supporting policy document at the time of our inspection. A policy was provided after our inspection.
• Risks were generally well managed though there was a lack of oversight of some risk associated with the premises including infection control and fire safety. We saw evidence that most of these risks had been addressed after the inspection.
• There were arrangements in place to protect children and vulnerable adults for abuse.
• Most staff had received essential training and adequate recruitment and monitoring information was held for all staff.
• Care and treatment was provided in accordance with current guidelines.
• Patient feedback indicated that staff were respectful and caring and appointments were easily accessible.
• The practice did not follow their own complaints policy by consistently responding to complaints in writing.
• There was a clear vision strategy and an open and supportive culture. However there were areas where governance was ineffective.

We identified regulations that were not being met and the provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

You can see full details of the regulations not being met at the end of this report.