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Inspection carried out on 12 December 2017

During an inspection to make sure that the improvements required had been made

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 carried out on 27 April 2017

During an inspection to make sure that the improvements required had been made

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. The overall rating for the practice was good but with requires improvement for safety. We carried out a focused follow up inspection on 21 and 24 June 2016 to check 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 15 and 16 October 2015. We found there had been some improvements at this inspection and the practice was rated as good for safety. The overall rating for the practice was good but with requires improvement for well led following this inspection as we found some areas for improvement relating to governance. The reports for both 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 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. 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 on 21 and 24 June 2016. Our key findings were as follows:

  • There had been some improvement in governance arrangements and staff responsibilities had been clarified to ensure governance systems were implemented. For example, the recruitment procedure and infection control action plan had been implemented and monitored.

  • Procedures to monitor vaccine fridge temperatures had been applied more consistently although these had not been effective in ensuring the correct temperatures were maintained.

  • Systems to ensure patient records were stored securely had been improved.

In addition the provider had:

  • Implemented systems to improve the availability of non-urgent appointments.

  • Improved complaints investigation records.

The practice must improve the following areas:

  • The provider must improve cold chain monitoring arrangements to ensure correct temperatures for vaccine storage are maintained. The provider must ensure all those involved in administering vaccines and monitoring the temperatures of vaccine storage understand what to do in the event of a failure in the cold chain.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 21 and 24 June 2016

During an inspection to make sure that the improvements required had been made

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of this practice on15 and 16 October 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to the regulatory breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulation 12, safe care and treatment, and Regulation 19, fit and proper persons employed.

We undertook this focused inspection on 21 and 24 June 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for on our website, St Ann's Medical Centre, at www.cqc.org.uk. Overall the practice is rated as requires improvement.

Specifically, following the focused inspection we found the practice to be requires improvement for providing safe, responsive and well-led services.

Our key findings across all the areas we inspected were as follows:

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 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.
  • There was a still a lack of management monitoring to ensure all policies and procedures were being implemented and appropriate records were maintained and stored securely.

Importantly, the provider must:

  • Improve governance arrangements and clarify staff responsibilities to ensure governance 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.

  • Patient records must be stored securely.

In addition the provider should:

  • Improve the availability of non-urgent appointments.

  • Maintain records of complaints investigations.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 15 and 16 October 2015

During a routine inspection

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

CQC Insight

These reports bring together existing national data from a range of indicators that allow us to identify and monitor changes in the quality of care outside of our inspections. The data within the reports do not constitute a judgement on performance, but inform our inspection teams. Our judgements on quality and safety continue to come only after inspection and we will not make judgements on data alone. The evidence tables published alongside our inspection reports from April 2018 onwards replace the information contained in these files.