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Inspection Summary


Overall summary & rating

Good

Updated 9 February 2018

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Ann’s Medical Centre on 15 and 16 October 2015 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The overall rating for the practice was good but with requires improvement for safe. We carried out a focused follow up inspection on 21 and 24 June 2016 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection. We found there had been some improvements at this inspection. The overall rating for the practice was good with good for safe but with requires improvement for well led as there were areas for improvement relating to governance.

We carried out a focused announced inspection on 27 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 21 and 24 June 2016. We found there had been some improvement in governance arrangements although these had not always been effectively implemented and the practice continued to require improvement in well led.

The reports for these inspections can be found by selecting the ‘all reports’ link for St Ann’s Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 12 December 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in April 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as Good.

Improvements to meet regulations had been made since our last inspection in April 2017. Our key findings were as follows:

  • There had been improvement in governance arrangements to ensure vaccines were stored safely.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 31 August 2016

The practice is rated as requires improvement for providing safe services.

The provider had implemented a number of improvements recommended at the last inspection for example they had;

  • Implemented systems to identify risks relating to infection prevention and control and to monitor and maintain standards. Maintained systems to minimise the risk of cross contamination in relation to hand washing at the branch surgery.

  • Improved recruitment procedures although the recruitment procedure was not fully implemented.

  • Implemented systems for formal analysis of significant events to enable the practice to identify patterns and trends over time.

  • Clarified who was responsible for managing medical alerts and implemented systems to ensure these had been actioned.

  • Improved arrangements for the storage of oxygen and ensured appropriate and consistent signage was implemented for oxygen storage areas.

  • The practice does however, need to improve governance arrangements and clarify staff responsibilities to ensure systems are fully implemented. For example, the recruitment procedure, infection control action plan and procedures to monitor vaccine fridge temperatures at the branch surgery must be fully implemented and monitored.

Effective

Good

Updated 24 December 2015

The practice is rated as good for providing effective services. Data showed patient outcomes were average for the locality. Staff referred to guidance from the National Institute for Health and Care Excellence and used it routinely. Patients’ needs were assessed and care was planned and delivered in line with current legislation. This included assessing capacity and promoting good health. There was evidence of completed clinical audit cycles and evidence these were driving improvement in performance to improve patient outcomes. Staff had received training appropriate to their roles and any further training needs had been identified and appropriate training planned to meet these needs. However, a record of all training completed was not maintained. There was evidence of appraisals and personal development plans for some staff. Staff worked well with multidisciplinary teams.

Caring

Good

Updated 24 December 2015

The practice is rated as good for providing caring services. Data showed that patients rated the practice higher than others in the local area for some aspects of care. Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. Information for patients about the services available was easy to understand and accessible. We also saw that staff treated patients with kindness and respect, and maintained confidentiality.

Responsive

Good

Updated 31 August 2016

The practice is rated as requires improvement for providing responsive services.

  • The practice had introduced a number of measures to improve access for patients. However, we received variable comments. Some patients said they had noticed an improvement and some said they still found it difficult to make a routine appointment and said that there was a lack of continuity of care. Urgent appointments were available the same day.

  • Minimal records of investigations of complaints were held.

Well-led

Good

Updated 9 February 2018

Checks on specific services

Older people

Good

Updated 31 August 2016

The provider is rated as good for safety and responsive and requires improvement for well-led. The findings which led to these ratings apply to everyone using the practice, including this population group.

People with long term conditions

Good

Updated 31 August 2016

The provider is rated as requires improvement for safety, responsive and for well-led and good for effective and caring. The concerns which led to these ratings apply to everyone using the practice, including this population group.

Families, children and young people

Good

Updated 31 August 2016

The provider is rated as good for safety and responsive and requires improvement for well-led. The findings which led to these ratings apply to everyone using the practice, including this population group.

Working age people (including those recently retired and students)

Good

Updated 31 August 2016

The provider is rated as good for safety and responsive and requires improvement for well-led. The findings which led to these ratings apply to everyone using the practice, including this population group.

People whose circumstances may make them vulnerable

Good

Updated 31 August 2016

The provider is rated as good for safety and responsive and requires improvement for well-led. The findings which led to these ratings apply to everyone using the practice, including this population group.

People experiencing poor mental health (including people with dementia)

Good

Updated 31 August 2016

The provider is rated as good for safety and responsive and requires improvement for well-led. The findings which led to these ratings apply to everyone using the practice, including this population group.