The Care Quality Commission
  • Doctor
  • GP practice

The MacMillan Surgery

Overall: Good read more about inspection ratings

The St Chads Centre, St Chads Drive, Liverpool, Merseyside, L32 8RE (0151) 244 4550

Provided and run by:
Dr Kok Foon Thong

Important: This service was previously registered at a different address - see old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The MacMillan Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The MacMillan Surgery, you can give feedback on this service.

30 June 2021

During an inspection looking at part of the service

Following our previous inspection on 25 September 2019, the practice was rated good overall and for all population groups but was rated requires improvement for providing safe services.

We carried out an announced desktop review of The MacMillan Surgery on 30 June 2021.

Overall, the practice remained rated as Good.

The rating for the key question followed up was:

Safe - Good

The other key questions remain unchanged as Good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The MacMillan Surgery on our website at www.cqc.org.uk

Why we carried out this review

This review was a focussed review of information without undertaking a site visit. This was to follow up on the key question - Safe.

We reviewed the breaches in the Regulation 19 HSCA (RA) Regulations 2014 Fit and proper persons employed. The regulation was not being met because: the system for ensuring that all the required documentation to demonstrate safe recruitment and ongoing staff suitability was not in place.

We reviewed breaches in the Regulations 15 HSCA (RA) Regulations 2014 Premises and Equipment. The regulation was not being met because: The provider did not have robust systems in place to assess the security of the premises and equipment and to identify health and safety risks or to take action to address them. Consulting rooms and the back-office areas were not secure.

We also reviewed the areas where the provider should make improvements by:

  • Providing reception staff with formal training for identifying and responding to patients with suspected sepsis.
  • Monitoring processes for checking uncollected medicine prescriptions.
  • Increasing the frequency of high-risk medicines searches to ensure the required patient health checks were timely.
  • Retaining training certificates to confirm the courses that have been completed.
  • Formalising clinical reviews and recording clinical staff supervision and monitoring.
  • Reviewing systems used to encourage patients to cooperate with health screening and childhood immunisation vaccine initiatives.
  • Providing formal training for non-clinical staff in the Mental Health Capacity act 2005 and the Deprivation of Liberty Safeguards (DoLs).
  • Offering personalised care plans to patients.

How we carried out the review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our reviews differently.

This review was carried out without visiting the practice. This was with consent from the provider and in line with all data protection and information governance requirements.

This included

  • Conducting staff interviews using video conferencing
  • Requesting evidence from the provider
  • Reviewing action plans sent to us by the provider

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 and Good for all population groups.

We found that:

The breach of regulation 19 HSCA (RA) had been addressed to ensure that all the information specified in Schedule 3 HSCA was readily available for each person employed. Evidence of pre-employment health checks and ongoing checks of registration were provided.

The breach of regulation 15 HSCA (RA) had been addressed to ensure consulting rooms were secure and all sensitive information and documents were kept securely in line with data protection requirements. Evidence that consulting rooms were kept locked as required and computer smart cards removed was provided. The security policies and procedure had been strengthened and smart lock and key systems had been installed. The provider monitored adherence to the policies and remedial action was taken as required.

  • The provider had taken effective steps to ensure staff knew how to identify and respond to patients with suspected sepsis.
  • The collection of prescriptions was now monitored.
  • The frequency of high-risk medicine searches had been increased to monthly.
  • Training certificates were retained and copies readily available for scrutiny.
  • Processes were in place for recording formal clinical reviews concerning all levels of clinical and non-clinical staff.
  • Evidence indicated that action taken in partnership with other members of the Primary Care Network were having a positive effect on the uptake of cervical screening and childhood immunisation.
  • The provider was in the process of sourcing Mental Capacity Act and Deprivation of Liberty training for non-clinical staff.
  • The provider confirmed that care plans were provided to patients with asthma as required.

We found no breaches of regulations.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

25/09/2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at The MacMillan Surgery on 25 September 2019. We carried out an inspection of this service due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

  • Safe
  • Effective
  • Well Led

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 and Good for all population groups.

We rated the practice as requires improvement for providing safe services because:

  • The system for ensuring that all the required documentation to demonstrate safe recruitment and on-going staff suitability was not comprehensive.
  • Systems were not in place to assess the security of the premises and equipment and to identify health and safety risks or to take action to address them.

We rated the practice as Good for providing effective and well-led services because:

  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance.
  • The practice had a programme of quality improvement activity in place and they reviewed the effectiveness and appropriateness of the care provided.
  • Staff had the skills, knowledge and experience to deliver effective care, support and treatment.
  • There was good communication between staff and staff told us they felt well supported.
  • The practice sought the views of patients and staff and acted on them.
  • There was a focus on continuous improvement.

The area where the provider must make improvements are:

  • Systems and processes must be in place to ensure specified information is available regarding each person employed.
  • Systems must be in place to assess the security of the premises and equipment and to identify health and safety risks and to take action to address them.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements:

  • Reception staff should be provided with formal training on identifying and responding to patients with suspected sepsis.
  • The provider should monitor the revised process for checking uncollected prescriptions.
  • Amend the procedure for monitoring high risk medicines to include the frequency at which searches are undertaken to check patients are receiving the required checks.
  • Retain training certificates to demonstrate staff training.
  • Formalise the system for reviewing the practice of clinical staff to ensure consultations, referrals and prescribing are appropriate.
  • Review the systems in place to encourage patients to attend for cervical and bowel cancer screening and childhood immunisations to increase uptake where possible.
  • Provide formal training to non-clinical staff in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).
  • The practice should look at providing detailed personalised care plans for patients who would benefit from this.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

25 February 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

This is the report from our inspection of The MacMillan Surgery. The MacMillan Surgery is registered with the Care Quality Commission to provide primary care services.

We undertook a planned, comprehensive inspection on the 25 February 2015 at The MacMillan Surgery. We reviewed information we held about the services and spoke with patients, GPs, and staff.

Overall the practice is rated as good.

Our key findings were as follows:

  • There were systems in place to mitigate safety risks including analysing significant events and safeguarding. The premises were clean and tidy. Systems were in place to ensure medication including vaccines were appropriately stored and in date.
  • Patients had their needs assessed in line with current guidance and the practice had a holistic approach to patient care. The practice promoted health education to empower patients to live healthier lives.
  • Feedback from patients and observations throughout our inspection highlighted the staff were kind, caring and helpful.
  • The practice was responsive and acted on patient complaints and feedback.
  • The staff worked well together as a team.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Implement a system whereby it is clear what training staff have received and when they are due to receive refresher training.
  • Ensure all staff are up to date with infection control training.
  • Ensure policies and procedures are practice specific.
  • Carry out a risk assessment regarding the availability of oxygen for response to medical emergencies.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice